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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY S VICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> YES NO O YES NO <br /> DISIBIBUTION SHOWN ON THE INSTRUCTION SHE[I ON THE BACK CAGE OF THIS F�CR}� <br /> REPORT DATE Q /�/, CASE• /j•..5,- j j, <br /> - D uI V / r S GRED _ b` IDATEE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SII]yA <br /> v Il/� ea S ( I ff-A33� �l�l <br /> w REPR ELATING O OWNERIO ERATOR Q REGK)NAL BOARD COMPANY OR AGENCY NAME r <br /> ¢ LOCAL AGENCY OTHER env b <br /> 8 <br /> a AD RESS CZ�T <br /> ll✓� <br /> N• STREET Joy ��� ��' Cm � TATE SIP <br /> j NAME n T�7 CONTACT PERSON PHONE <br /> Z D L 5 - I I 5 Q UNKNOWN <br /> r 0 g ADORESS (�� S <br /> syn <br /> w ) C. <br /> OCITr gTATE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE �l <br /> a <br /> ADDRESS <br /> { O Y s<ceE�-�� w i �• IKi/ I cmr' ..7�^-' AcoTHiS U�{� m <br /> CROSS STREET <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE ( _ <br /> M45 /eltD <br /> 2. REGIONAL BOAAD PHONE <br /> m p) NAME QUANTITY LOST(GALLONS) <br /> 0 5o� ��� <br /> <j UNKNOWN <br /> m� m <br /> UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> 2 <br /> v .SLI Dq D r r TANK TESTTANK REMOVAL a OTHER <br /> - < DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> 6 <br /> cUNKNOWN OREMOVE CANTENTS CLOSE TANK&REMOVE aREPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 /,(� 1�+{{ REPAIR TANK O CLOSE TANK&FILL IN PUCE ❑CHANGE PROCEDURE <br /> .� L YES E NO IF YES.DATE Du 5uI V of 1 r y REPLACE TANK O OTHER <br /> 'a SOURCE OF DISCHARGE CAUSE(S) <br /> c'< TANK LEAK UNKNOWN 7 OVERFILL Ej RUPTURE/FAILURE O SPILL <br /> - y0 F-] PIPINGLEAK F-1OTHERD CORROSION IXI UNKNOWN O OTHER <br /> w w CHEC NE ONLY "'1 <br /> 0 UNDETERMINED SOIL ONLY O GROUNDWATER ID DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> .� CHECK ONE ONLY <br /> wZ 0 NO ACTION TAKEN O PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED E:] POLLUTION CHARACTERIZATION <br /> jy ❑ LEAK BEING CONFIRMED F PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) F-1 EXCAVATE&DISPOSE(ED) REMOVE F REE PRODUCT(FP) Q ENHANCED BIODEGRADATION(IT) <br /> Ivi A•u rw m.usl <br /> Z4 CAP SITE(CD) O EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> w CONTAINMENT BARRIER(CB) NO ACTK)N REQUIRED(NA) TREATMENT AT HOOKUP(HU) O VENT SOIL(VS) <br /> e <br /> VACUUM EXTRACT(VE) 7] OTHER(OT) <br /> _ Fvrthetr 5l gS5Gs5m W6�1gvly <br /> . �niv✓e sand e�(+2nf- n4e cc g4gm i r)a Ihon <br /> as re uLre� b -Vie a prDpCi&(e r"ala 4,9e. 6 <br /> y„ R9C 651d'rN <br />