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U -u <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)./,CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERG SERVICES FOR LOCAL AGENCY USE ONLY - <br /> I ❑ YES ND REPORT BEEN FLED? YES ❑ ND I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE ANDTHAT E HAVE <br /> DEPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 251807 OF., <br /> REPORTOATE CASEA THEHTKAN SAFTYCOD - <br /> (> C! ( �.� t <br /> U M4M o r r $�iN D DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNAP RE <br /> REPRESE ING ❑ OWNE WOPERATOR;II ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> OLOCALAGENCYY�❑ OTHER s/,�J �]-% - (-,• A 14� I�' <br /> ADDRESS //. %' <br /> PT V " STREET Cir SMRTE ZIP <br /> w NAME {/ C/ONN�TACTPERSON 'PH�O'NE,�)I <br /> i� S' Cn , 1.-;�'J sCi - ❑ UNKNOWN 1.i�1. J \M-..LN�YK.'��C•° /' /C"L // / ��� /D <br /> ga ADDRE$$�� GCry <br /> STREET CRr SfPTE DP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o SUS e&z' I .5'u .D-S 9�/S'-yo-7 <br /> a ADDRESS `' Ij <br /> l q -3,,- �C <br /> CITY 7 SaG J <br /> STREET CWNTr ➢P <br /> rn CROSSSTREET <br /> O LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> =w S�Co f HS� � �-7, IJ ; fJ ��d-r,�c •U' ` (S7/Y(-' ,�.2oX'`/��k 3 f-� � <br /> U <br /> w C REGIONAL BOARD PHONE <br /> m (I) NAME / QUANTITY LOST(GAL <br /> UNKNOWN <br /> FO G l <br /> m 2 <br /> N- .. lyhw �/I•(r..Q_.�Y LC. � /c Ki' /•l.L.� ❑ UNKNOWN <br /> i //DAyyTE DISCO /QED '/'J; HOW DISCOVEV D O INVENTORY CONTRO ❑ S SURFACE MONITORING ❑ NUISANCECONOITIONS <br /> Ll M M `-' o o L r r ❑IV TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN ,., METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> �w M M o D r y I�KNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> I O HAS DISC EBEEN STOPPED? ❑ REPAIRTANK ,, 11❑ RREPAIRPIPING. ❑ CHANGE PROCEDURE <br /> f o YES ❑ NO IF YES,DATE ✓M `M I p ` 13 ! '1 Y ❑ OTHER r W Y`C.� i <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢� ❑ TANKLEAK ❑ UNKNOWN ❑ OVERFILL ❑- RUPTURE/FAILURE ❑ SPILL <br /> IPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> I ww CHECK ONE ONLY <br /> ❑ UNDETERMINED Ce/SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKO ONLY <br /> Fy <br /> wF NO ACTION TAKEN 1-:1PRELIMMARYSITE ASSESSMENT WORKPLAN SUBMffTED ❑ POLLUTION CHARACTERIZATION <br /> ¢Q <br /> aF PRELIMINARY SITE ASSESSMENT UNDERWAY E::] POST CLEANUP MONITORING IN PROGRESS <br /> ❑ LEA(BEING CONFIRMED ❑ <br /> ON ❑ REMEDIATION PLAN - ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PROOUCT(FP) ❑ ENHANCED BIODEGRADATION IT) <br /> ISxcxTwoEl�u.W <br /> ES ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET)- E-] Pump BTREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> a� C ( ) ACTION REQUIRED INA) ❑ TREATMENT AT (HU) ❑ VENTSOIL(VS) <br /> r7 CONTAINMENT BARRIER(CB) O/0'_0 HOOKUP <br /> �( <br /> ❑ VACUUM EXTRACT(VE) Iry IY OTHER(OT) �L' ' d.SSL�SS}7'!G'-YI/IJ• <br /> K �,.. d 2G1 �4C� SCS" 2� �L�C,�/1DCe: /�/`� -"it rtLtG�GI ifs - <br /> C%vrw ?Gf�Vnd���Y� r1 fC z '�iz� Y•c � J� O�gd E -!>>11se ( w -0 <br /> 220 <br /> NSC DSII,I&N <br /> /-u a 0 <br />