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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES NO REPORT BEEN FILED 4 0 YES ❑ NO I HEREBY CERTIFY MT 1 HAVE DISTRfi3UTEOTHIS INFORMA71ON ACCORDING TO THE <br /> DISTRIBUTKW SHOWN ON THS INSTRUCTION SHEET ON THE$11+~K PAGE OF THIS FORM <br /> I REPORT DATE CASE$ <br /> M M Y SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> I m <br /> ( )C1-ilrb-- fty"", <br /> w <br /> REPRESENTING OWN RAOPERATOR Q REGIONAL BOARD COMPANY OR AGENCY NAME <br /> us❑ LOCAL AGENCY ❑ OTHER c <br /> U, <br /> ADDRESS <br /> BTREEf CRY STATE I lk <br /> y <br /> CONTACT PERSON PHONE <br /> m p UNKNOWN <br /> 9 <br /> Z Q - - -- - - - - -' <br /> a ADDRESS <br /> Na <br /> ¢ (V REEF GTY STATE •VV _ZIP <br /> - <br /> A){�J <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o s <br /> � t 1 <br /> ADDRESS0h <br /> OrrrA <br />' N CROSS STREET <br /> La <br /> mom <br /> O LOCAL AGENCY AGENCY NAME TACT PERSON PHONE <br />' Lu .n ovin v (�� [ r; ('q 1 6�-3 LY <br /> w n REGIONAL BOAR PHONE <br /> w` - eW 46.13 Corr o f 1255-351q <br /> ally <br /> y (ir �y T r� 4- NAME QUANTITY LOST(GALLONS) <br /> C.. lO U +G�V1 1R L 1 b V�Z Y1 l Q�� 5 �UNKNOWN <br /> Lu <br /> x� <br /> 4� <br /> m O {� a <br /> Vn I PCc S 1 T i3 F. T 1 fi y 231 UNKNOWN <br /> i DATE DISCOVERED �yHOW DISCOVERED ❑ INVENTORY CONTROL �' SUBSURFACE MONITORING L3 NUISANCE CONDITIONS <br /> m 0.' - 4 rLJ p O Y Y ❑ TANK TEST ❑ TANK REMOVAL OTHER <br />' m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> )Sa;:GNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> y D Y <br /> HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br />' a ❑ YES NO IF YES DATE y 4 D Y v ❑REPLACE TANK ❑OTHER <br /> w SOURCE OF DISCHARGE CAUSE(S) <br /> j a ❑ TANK LEAK UNKNOWN ❑ OVERFILL 0 RUPTURElFAILURE ❑ SPILL <br />' 0[i E] PIPING EAK F-1OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> u+uu CHECK ONE ONLY <br /> tz a <br /> O ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER E:] DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />' CHECKONEONLY <br /> w f �[❑] NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBINITTED Q POLLUTION CHARACTER17ATION <br /> ¢ LEAK BEING CONFIRMED Q PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> Uy <br />' REMEDUITK)N PLAN ❑ CASE CLOSED(CLEANUP COMPLETED DR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> a z s�enc PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> n o ❑ CAP SITE(CDA ❑ EXCAVATE&TREAT(ET) ❑ ❑ <br /> aLa <br /> ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIR D(NA) TREATMENT AT H KUP(HLA) VENT SOIL S7 <br /> ❑ <br /> 'Ni <br /> VACUUM EXTRACT(VE) OTHER(OT) <br /> VJ ► ! �✓! ✓`-` <br />' Max '(;3eWz�,n = 23 /� .1wax nl u en e = 3p� y/L; <br /> Wako\ )<I I eh e-,>= 2�-.��-/L; , � / Q = 9-S �� I A4o-X U I P� =-q.,7•��— <br /> HSC 05(8901 <br />