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11/13/2003 09:04 9497231854 FREY ENVIRONMENTAL PAGE 13/1 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)If CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE DFFICEOFEMERGENCY SERVICES FOp;].00ALAGENCXU360NLY <br /> REPORT BEEN FILED9 1HEFEEY CERTEYTHAT#WIVEDISTfl1BtIffD�i115INFORMA'CIDN ACCDRDPIGTD THE <br /> YES ® ND ❑YES � NO D44TR19D7 ISHDIYNS3Tl TIiK.INSYAUCTiDN SFIEETtltiCRI BACM CCORP TUP.... <br /> REPORTDATECASI=A 4 -� <br /> M <br /> 1 3 <br /> N M <br /> NAME OF INDIVIDUAL FILING REPORT -PHONE SIGNATURE <br /> m <br /> rvac� R I�crs (CHI -7aa� Ir. �� <br /> w REPRESENTING ® pWNERICPERATOR ❑ REGIONAL BOARD DOM <br /> PANYOR AGENCY NAME <br /> g ❑ LOCAL AGENCY ❑ OTHER_ �'`+�� E.s�IIRaIJWYbt`Tf�C1.�1 1ntL1 <br /> ADDRESS <br /> a%n A L-PrF/YE,� AP--. ►JEwFaf r 6E r+ +✓a� �uZIP <br /> P <br /> w NAME CONTACT <br /> PERSON --FP—HONE <br /> y UNKNOWN LgNt-N -OaL36LJp,) (AG IJ / 'LILp <br /> mADDRESS <br /> `Ju11s -jell (f\L)gFP.G-v3P.7c)RO �i"1t?JC7 <br /> el'll E cl r STATE ZIP <br /> FACILfTY NAME(IF APPLK:ASLE) OPERATORPHONE <br /> �u1xR tG Ve?, AyLJCIccj ,.TTicL (2091 X43_ 37A <br /> UADDRESS <br /> s 3�� -D QC.W- C.Re�+�i 1.tE Slack cal� 5� )oAQuI J 8526 <br /> 31TIED cm mulM ZIP <br /> y CROSS STREET <br /> �jTAcCo6CC9 RCt'l T��.J/T}/ <br /> i LOCAL AGENCY AGENCYNAME CONTACTPERSON PHONE <br /> '`JA�1 �pAC9,ufl�t �Jr.T'� Gov, Ih.�{ �1NPA A?A-l-,- (2,LA) 4(,%- -�LMb <br /> W REGIONAL BOARD PHONE <br /> sa ( ) <br /> y (1) T NAME QUANTITY LOST(GALLONS) <br /> 1✓t�� UNKNOWN <br /> TA <br /> `A ❑ UNKNOWN <br /> DATE DISCOVERED 7� HOW DISCOVERED E] INVENTORYCONTROL ❑ SUBSURFACE MONITORING)ORG ❑ NUISANCE CONDITIONS <br /> oM <br /> %.I0Y `ter ❑ TANKTEST ❑ TANK REMOVAL OTHERQIQI t446i 171SP�NSrR.RE'X'nOVft;l.. <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w <br /> .1 Yl r <br /> ❑ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE(T(��A��NK��&,FILL��IN PUCE Q CHANGEPROCEDURE <br /> o YES ❑..NO IF YES,DATE L.)M 9� I '_ ay 3y ❑REPLACE TANK gOTHER9JEPLAPr,- ISp. I4ND 1"ltllt'IET <br /> `u SOURCE OF DISCHARGEt CAUSES) <br /> D¢qj ❑ TANK LEAK F-1UNKNOWN ❑ OVERFLL ❑ RUPTUREFAILURE ❑ SPILL <br /> �O ❑ PIPINGLEAK ®„OTHER" CORROSION UNKNOWN ❑ OTHER <br /> mw CHECKONEONLY <br /> O UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER '(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> Z ❑ NOACTIONTAKEN PRELIMNARVSTTEASSESSMENTWORKPLANSUBMITTED ❑ POLLUOONCHARACTERIZATION <br /> �,a.. ❑ LEAXBEINGCONFIRMED F-] PREWAINARYSITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> Oy ❑ REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK APPROPRIATEACTDN(S) TCl EXCAVATE L DISPOSE REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION <br /> (�4OtfOPOEfN1P IJP (ern ❑ ❑ (m <br /> 8 ❑ CAP SITE(CD) ❑ EXCAVATES TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(OT)❑ REPLACE SUPPLY(RS) <br /> 2a ❑ CONTAINMENT BARRIER(CM ❑ NO ACTION REQUIRED INA) ❑ TREATMENTATHOOKUP(HU) ❑ VENTSOIL(VS) <br /> A❑ VACUUM EXTRACT(VE) ED OTHER OTHER(O <br /> M",` <br /> y Fol IW1Ai-CLY '31) 'RIAS GF tlmiL. 1"IXLAVAIZ,D Yq,,3� lJt-,A..4" <br /> TtFi "MNE� 'VI65F L- i�1i4@a56RS. 3o L oT I L L 6`3 `(RM3St�trR1E1� "tU �At TIBSLMA— <br /> RScm(I <br />