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I I%fto, 7.2 — LA a6 *'W" <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR,LOCAL AGENCY USE ONLY <br /> YES NO <br /> REPORT BEEN FILED? YES i HEREBY CERTIFYTHAT ..HAVE DISTRIBUTED THIS INfORMAIION"ACCORDING TO THE> <br /> ❑ ❑ NO <br /> DISTRIB ON aWOWN WHIP IINSTRII TIO4SHEETON IleBAC PAGE Of THIS FORM <br /> 41. <br /> REPORT DA DCA5Es <br /> RE <br /> ° _`., . DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SI PURE <br /> ! IIl�i�j <br /> wREPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENRV AME <br /> cc <br /> iL <br /> GENCY ❑ OTHER <br /> cc ADDRESS� <br /> 14/4 :Yaelo4'�.�•u-5T. <br /> STREET CITY STATE ZIP <br /> LL, <br /> NAME CONTACT PERSON PHONE <br /> Z <br /> ❑ UNKNOWN ( ) <br /> 2 <br /> OCL as ADDRESS ,�.,, l <br /> LLJZ ��7�" Aj- eGG� r� '�_ /7���D Gia STREET CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) LJ OPERATOR PHONE �J <br /> ��f/f ✓ /PLS/� �/Q� `�1►- �1 �� ���i� (Z �7 +f/ <br /> a <br /> ADDRESSr� <br /> STREET CITY COUNTY ZIP <br /> W <br /> y CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> W w REGIONAL BOARD PHONE <br /> as <br /> U) NAME QUANTITY LOST(GALLONS) <br /> W o KNOWN <br /> �J <br /> In Z (2) pp <br /> H ❑ UNKNOWN l <br /> Z DATE D7m, <br /> ERED HOW DISCOVERED F-1I TORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w Or� Q oI To) vI ❑ TANK TEST FZ"TANK REMOVAL ❑ OTHER V <br /> 6 <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Q UNKNOWN <br /> E:]REMOVE CONTENTS E]CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> M o r <br /> 0O HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> `� ❑ YES ❑ NO IF YES,DATE r [:]REPLACE TANK ❑ OTHER <br /> � M� � o r>I v <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> j ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RU REIFAILURE ❑ SPILL <br /> y O F7 PIPING LEAK F-1OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> W wa CHECK ONE ONLY <br /> U ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER •(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK O NlY <br /> w NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> CC�< ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ti ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> Q Z I�eiu raa oerusl <br /> F3 O ❑ CAP SITE(CD) ❑ EXCAVATE 3 TREAT(ET) ❑ PUMP d TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Lu <br /> Lu a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> cn <br /> rP�✓rEKi oGiL PeESa,G�S �Z'��c, tic- reeG•t*v��� r.�i;�.c��-� �� <br /> W �v d c.��cl.�T. ! 7��i� ,ZE c�E�tfT—/`�vf-t�' )ee—a 4vi j <br /> 0 .:.rr� --vF 4:7177 ,te/v laR <br /> Ii3C 0.S I819q <br />