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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY:USE ONLY <br /> REPORT BEEN FILED? 1`HEREBY CERTIFY THAT t AM f4DESiGNA7EQ GOVERNMENT EMPLOYEE ANQ THAT E HAVE <br /> ❑YES ❑ NO ❑YES [�NO tiEpORTEQ,THIS INFORMATIOK TO LOCAL#F1CfALS Pl)R5()ANT TO SEET(ON 2511. OF <br /> REPORT DATE CASE s "THE H AN <br /> (,� SIGNED DATE <br /> L .. <br /> I Mf / MI 2 V pl Y Y <br /> NAME OF INDIVIDUAL FILING REPORT PHONE <br /> (z--q) <br /> 4165"-31-1-meq <br /> REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> O [D-LOCALAGENCY ❑ OTHER �jEi� Jt?46. vlK �'v Poy,-ii ,NfJ�Gr-t ��e2Vf <br /> w <br /> ADDRESS <br /> L fV� �,ON PHONE <br /> STATE ZIP <br /> NAME"77/ CONTACT PERS <br /> z Q Dc2� ► ir`cF�t i Cvui'�1NY�N(_ ❑ <br /> UNKNOWN S l�n(G6� 144004E (��`+)`l5" <br /> g a ADDRESS r, <br /> PQ• 1'7 o/ J p v� STREEr crrYh+ � C'�•- STATE L ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> a ADDRESS <br /> f�J�t' �- ?%.Qc'vc«,NTY � h/�u v <br /> w ) STREEr Ctry <br /> CROSS STREET <br /> c7 LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> 4w5.4N '124 t; <br /> t-(7• /�b'��fL lff�fGTd( rlF�i t�-��� �—/�IL t���1a (2`'ct) �E��H3 <br /> Z U <br /> z PHONE <br /> J REGIONAL BOARD ( ) <br /> as <br /> 9 w�G QUANTITY LOST(GALLONS) <br /> w (11) 7'NKl--13,15:44 N NAME <br /> U w ❑ UNKNOWN <br /> a� <br /> m> t� xYc-FiN� <br /> — �) T'P� ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 2NK M / •-? 6 l p ❑ TANK TEST ❑ TAREMOVAL ❑ OTHER <br /> M -D D Y Y <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> dUNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK dCLOSE TANK <br /> W M M D D Y V <br /> O HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> o ❑ YES ❑ NO IFYES.DATE M .1 1 D oI r YL ❑ OTHER <br /> La w SOURCE OF DISCHARGE CAUSES) <br /> a ❑ TANK LEAK UNKNOWN ❑ OVERFILL E] RUPTURElFAILURE ❑ SPILL <br /> v ❑ PIPING LEAK F-1 OTHER <br /> F-1CORROSION ©UNKNOWN ❑ OTHER <br /> Lu w CHECK ONE ONLY <br /> c� ❑ UNDETERMINED d SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> rn ❑ POLLUTION CHARACTERIZATION <br /> Z� ❑�NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED <br /> j y ❑ LEAK BEINGCONFIRMED F7PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTIONS) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> z Im.FMOUALM r+UMP 8 TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> o Q ❑ CAP SITE(CD) F-1 EXCAVATE b TREAT(E7) El <br /> LU v TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> w a ❑ CONTAINMENT BARRIER(C8) ❑ NO ACTION REQUIRED(NA) ❑L I <br /> ❑cc <br /> VACUUM EXTRACT(VE) OTHER(OT) SC e <br /> FG'krTNE� 51 TE.955FS` uir�L QF /�Eu✓t�Pi� rD I'- <br /> t't^rG THE hITvRF 4N4 <br /> xT'�iv't—�'F cvt�-r. ��v�Tront sFQ,,�i,�Er� 11511 -TN c- Ai''�kuPAi,di't RFG�L. -vRy <br /> NSCOSIII/o <br />