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* ,0 - <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY.USE ONLY <br /> REPORT BEEN FILED 7 El ❑ NO 1 HEREBY CERTIFY THAT I.HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ YES Q NO DISTRIBUTI�tJSHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORTDATE CASE R 1 j <br /> DA E <br /> ' <br /> N N O Y SIGNED SIGN TUBE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE <br /> P. <br /> W REPRESENTING EOOWNER/OPERATOR ❑ RK) <br /> EGNALBOARD COMPANY OR AGENCY NAM <br /> ❑ LOCAL AGENCY ❑ OTHER S1 Gera, LAjmlj r ManA1�0.0 L1 S <br /> SADDRESSGAu.Zel�e <br /> w P CITYSTATE ZIP <br /> STREU PHONE <br /> J NAME CONTACT PERSON ( <br /> UNKNOWN I_Qr/ J9) q4�-171 <br /> Z� Joscp�. P. ECL cr ❑ R b r <br /> a n ADDRESS SF OGK�'O Pl C-A 861.03 <br /> a �77 l►J. N f1ZG`�6 ry AL1�. cin STATE IP <br /> STREET PHONE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR <br /> �«r <br /> z S2 cct a— 1 — ' <br /> a ADDRESS ` �jFCGY'K7 (� Man Jpp,(�,J � <br /> o ;3••1IJ LLI, 1'10.2C,�Or'f AJC- crtY wuNn ZIP <br /> J STREET <br /> W <br /> � CROSS STREET <br /> N Sco"S +- trlonro <br /> O <br /> AGENCY NAME CONTACT PERSON PHONE <br /> LOCAL AGENCY <br /> wwa <br /> ; n I�4f� A G I PHONE <br /> w z. REGIONAL BOARD <br /> NAME QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> Ow G 1� L <br /> Z <br /> Q J <br /> m (� ❑ UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL [ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> o OY Y ❑ TANK TEST ❑ TANK REMOVAL <br /> E OVA USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> < DATE DISCHARGE BEGAN <br /> UNKNOWN <br /> REMOVE CONTENTS CLOSE TANK&REMOVE E]REPAIR PIPING <br /> Yl Y ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> HAS DISCHARGE BEEN STOPPED 7 <br /> o BYES ❑ NO IF YES,DATE u uI o Y Y ❑REPLACE TANK ❑ OTHER <br /> pl SOURCE OF DISCHARGE CAUSES) <br /> 20 E] TANKLEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> NU E] PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w CHECKONEONLY <br /> U ❑ UNDETERMINED ❑ SOIL ONLY []2 GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> iW E] NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ¢? BLEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY <br /> U`� ❑ <br /> REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(11) <br /> J pffeax rmoer.�sl PUMPS TREAT GROUNDWATER(G T)❑ REPLACE SUPPLY IRS) <br /> a z ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(En ❑ <br /> wa CONTAINMENTSARRIER(CB) ❑ <br /> NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) R"'OTHER(OT) c n <br /> hL 'G is S'S gcrno�`ca_� '&S unV neju fl. I�lg3 '�S Fw <br /> ro % Ca��rc <br /> e""C.� AG OLe�csSec� �ISZ 4+scodcry Dur. nq Cencrc1� �� <br /> �mp►oyeeS L,u1,o L.,. J J <br /> 8 Rsca Is9al <br />