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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HASSTATE OFFICEOFEMERGENCYSERVICES OR({CAL AGENCY USE.CbN(.Y . <br /> REPORT BEEN FILED?YES ED N iHERE-BYCEFi lFYTHA'rl:HAVEl7IS�fttB(17EDTMSINF{�#�+I+ti7tkAC"WROtNGT0�FiE: <br /> NQ <br /> REPORT MATE: bEilliBUTION SHOWN`ON THE INStRUCTIDN SHEET-ON THE BACK PAGI:'OFV 6 FDRM. <br /> FCASE�.: , <br /> 6.1 10A7 Y SIGNM <br /> DATE'. <br /> NAME OF INDIVIDUAL FILINGEPq9T PHONE SIGNATURE <br /> LAPS-3 <br /> qY <br /> REPRESENTINGOWNERIOPERATOR F-1RE*NAL.WMRO I COMPANY ORAGENCY NAME <br /> tr. <br /> LOCAL AGENCY .OTHER <br /> .. <br /> ADRESS <br /> v <br /> CttY ... .Id�:.. ZIP <br /> LU NAMEi . CONTACTS PERSON Pte: <br /> z SIR jL/ /) Q UNKNOWN d l <br /> a ADDRESS <br /> w <br /> ¢ f ?. <br /> srATE::: <br /> FACILITY NAME{IF APPLICABLE} OPERATOR PHONE .......... <br /> ADDRESS, �/��� r ldGP: <br /> �TRift CITY Comy . <br /> w P <br /> ,�-� CROSS STREET <br /> LOCAL AGENCY AGENCY NAM CONTACT PERSON PHONE <br /> LAI 0 <br /> uzi REGIONAL BOARD WPHONE <br /> Q t it J t+ + *" �-. efib)4* qkS <br /> LU (3} NAME OUANTtTY LOST(QALLONS) <br /> z ui V -� UNKNOWN <br /> a�, <br /> 1; (2) <br /> CD <br /> aiz LrG� Ot t/ft-Cl NKNOWN <br /> 'DATE DISCOVERED /� HDW DISCOVERED INVENTORY CONTROL a SUBSURFACE MONITORING F-1NUISANCECONDITIONS <br /> n O Y r 0 TANK TEST TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> UNKNOWN F-�REMOVE CONTENTS OSE TANK&REMOVE O REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED? Q REPAIR TANK Q CLOSE TANK&FILL IN PLACE Q CHANGE PROCEDURE <br /> o YES Q:NO IFYEs,OATE �M Mj " �Y ❑REPLACE TANK Q OTHER <br /> -SOURCE OF DISCHARGE: CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN OVERFILL RUp3UREiFAILURE SPILL <br /> v PIPINGLEAK Q OTHER ED CORROSION 5 UNKNOWN Q OTHER.. <br /> w sy CHECK ONE ONLY <br /> UNDE fERMtNEI] Q SOIL ONLY' GROUNDWATCR DRINKING WATER •(CHECK.,ONI Y tFYVA7Eii WELLS HAVE ACTUALIY:BEEN AFPEGTED) <br /> CHECK ONE ONLY <br /> w NO ACTIOMTAKEN: E] PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION:CHARACTERIZ#TION <br /> s <br /> LEAK 615WOCONFIRMeo PRELIMINAW40i, SS ESSMENTUNDERWAYPOSTCLEANUPMONITORINGINP"ROGRES'S <br /> REMED1AT70N PLAN <br /> CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) Q CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) E7] ENHANCED BIO DEGRADATION(IT) <br /> wGAP SITE{CD} EXCAVATE 8 TREAT(ET) PUMP d TREAT GROUNDWATER(G) :REPLACE:SUPPLY(RS) <br /> w CONTAINMENTBARA(ER(CB) NO ACTION REQUIRED(NAf TREATMENT AT HOOKUP(WU} F VENT 9011,:(Vg) <br /> cc <br /> VAcuu41 xTRACTEj oTtrtOT) 1 ve <br /> W <br /> NSC 05( 1. <br />