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u Is <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ COWIVINAT1ON`SIT RE RT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? 1 • (�I��j F ` o <br /> YES NO VES NO THEREBY CERiiFY THATI HAVE DISTR .1 THIS(NF�RMATIONA000RDINGTOTHE <br /> DISTRIBUTION SHOWN ON THE INSTRUgTON 41EETON THE BACK PAGE OFTH� FORM <br /> REPORT_DATy CASE i 9{ <br /> , t S s 3w� / <br /> MI �MIy�r v SGNED (rl Y^ `PPC^ <br /> DATE._ <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> REPRESENTING CWNERIOPEIRI REGIONAL BOARD CI <br /> ANY <br /> OR AGENCY NAME <br /> g. LOCAL AGENCY OTHERP 14 <br /> ._ + t �.O . <br /> - ¢ ADDRESS <br /> srREET cm SIAM zlp <br /> NAME CONTACT PERSON PHONE <br /> (;ID <br /> /,j, J y <br /> z� ( f # I Y'. "�}t m4, C�✓� UNKNOWN (;ID�) 40 �J ✓1 <br /> p� <br /> ..,... ¢ .ADDRESS,-- <br /> SIPFET CITY $TRTE - ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o r G � iJ �i�CI\ G r <br /> Q ADDRESS - /'• <br /> IS <br /> 0 too <br /> ___ STREET 'CRY DODNTY ZIP <br /> ti CROSS STREET _ <br /> Ij LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> 1-4 1-i <br /> m REGIONAL BOARD T PHONE <br /> NAME QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> pw <br /> a� <br /> UNKNOWN <br /> r <br /> DATEIiISCOVEREDHOW DISCOVERED O INVENTORY CONTROL O SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> w W MI D of F v �f r TANK TESTTANK REMOVAL O OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN Ik]REMOVE CONTENTS CLOSE TANK 8 REMOVE REPAIR PIPING <br /> D D Y ' Y fT"L - - <br /> HAS DISCHARGE BEEN STOPPED T y7 �}}� -�/7 /Q} O REPAIR TANK OSE TANK E FILL IN PLACE O CHANGE PROCEDURE <br /> mo YES 0 NO IFYES;DATEM7 rw ✓So ! v v v �REPLACETANK OTHER <br /> SOURCE OF DISCHARGE .r— 7 CAUSE(S) <br /> ¢� O TANK LEAK UNKNOWN - F-I OVERFILL O RUPTURE/FAILURE 0 SPILL <br /> O O PIPING LEAK OTHER E::] CORROSION UNKNOWN a OTHER <br /> w w CHECK ONE ONLY - <br /> N R <br /> O UNDETERMINED O SOIL ONLY GROUNDWATER O DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z NO ACTION TAKEN O PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED E:] POLLUTION CHARACTERIZATION <br /> w <br /> ¢? LEAK BEING CONFIRMED a PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> pm O REMEDIATIONPLAN. CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) 0 CLEANUP UNDERWAY- - <br /> CHECK APPROPRIATE ACTIONS) 0 EXCAVATE&DISPOSE(ED) O REMOVE FREE PRODUCT(FP) ENHANCED BIODEGRADATION(IT) <br /> I�ancx ronoET.usl - <br /> a 0 CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) O PUMP E TREAT GROUNDWATER(GT)a REPLACE SUPPLY(RS) <br /> p0 <br /> w a. CONTAINMENT BARRIER(CB) E:] NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) O VENT SOIL(VS) <br /> n VACUUM EXTRACT(VE) OTHER(OT) <br /> '!f ,. /7 <br /> /s'V q✓ n !�%f e2 I t� <br /> Nsc cs IggN <br />