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� a <br /> ]UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTA NATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> REPORT BEEN FILED 7 `FOR LOCAL AGENCY USE ONLY:.:: <br /> ❑ <br /> YES �NO ❑ YES NO 1HEREBYCER7IFY�HAT1 NAVEDISTRiBUTEpTIiISINFORMATIONACCORDINGTOTHE <br /> REPORT DATE DiSTA IBUTION SHOWN ON TkE WSTRUCTION SHEET ON THE BACK PAGE OF THIS FOR M.. <br /> CASE s <br /> NAME OF INDIVIQUAL FILING REPORT SIGNED <br /> O PHONE ELATE <br /> m <br /> REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> X LOCAL AGENCY ❑ OTHER ^ <br /> � ADDRESS �VN f r � � D <br /> 3o F. We�REET , t 3�� Ffoor C� <br /> STT � o <br /> w NAME cSTATE [GG/// G.i <br /> � <br /> -' CONTACT PERSON ZIP <br /> �O JR n J, PHONE <br /> Cul <br /> a ADDR1ESSSj}.�(+�/ •t�/J]�J ❑ UNKNOWN k N S UA eT ,CI~ ( 2�)�y�_3'�3 <br /> O STREET CfTY S C4 <br /> FACILITY NAME(IF APPLICABLE) / STATE ziP <br /> DLfLo r v OPERv�AyTeO�R C F PHONE <br /> ADDRESS 01\ O i� - J 1 S S ( } <br /> U <br /> O W . <br /> w o i V V STREET V �� _r'� LAS+ 1 CITY Lo kJ' ��1 <br /> y CROSS STREET COUNTY <br /> RL) ZtP <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON <br /> z PHONE <br /> {�'J �p ( ^ (amu �,/ <br /> w w REGIONAL BOARD <br /> IL <br /> -0 J,f <br /> < ( VEL i I�u cr 64113-1 (4 � PHONE <br /> i <br /> 1 d�qr' r.� 016 )2.55-31t� <br /> 0 w ) - U NAME QUANTITY LOST(GALLONS) <br /> a J (V�rj <br /> m Oj NKNOWN <br /> r DATE DISCOVERED ❑ UNKNOWN <br /> w I NOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> �u MI �W D Dy?j y ❑ TANK TEST TANK REMOVAL OTHER <br /> a DATE DISCHARGE BEGAN <br /> m <br /> a METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> r <br /> cc <br /> M Di yl UNKNOWN ❑REMOVE CONTENTS OSE TANK 6 REMOVE F-]REPAIR PIPING <br /> O HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o ❑ YES ❑ NO (F YES,DATE m MI D y Y ❑REPLACE TANK ❑ OTHER <br /> SOUgCE OF DISCHARGE CAUSE(S) <br /> w ❑ <br /> TANK LEAK � UNKNOWN ❑ OVERFILL <br /> ❑ RUPTURE/FAILURE � SPILL <br /> O U <br /> y ❑ PIPING LEAK ❑ OTHER ❑ CORROSION <br /> UNKNOWN ❑ OTHER <br /> Lu <br /> 0 ILCHECK ONE ONLY <br /> U UNDETERMINED ❑ SOIL ONLY ❑❑ GROUNDWATER DRINKING WATER -(CHECK ONLY IF WATER WELTS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ~�' NO ACTION TAKEN <br /> Z ❑ ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ <br /> Lu POLLUTION CHARACTERIZATION <br /> Q <br /> w LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> o ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) E DISPOSE ED <br /> tsps. FDR XTEXCAVAT6 <br /> O ( ) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 910 DEGRADATION(117 <br /> o p CAP SITE(CD) EXCAVATE A TREAT(ET) PUMP TREAT GROUNDWATER G <br /> �"~ ❑ ( T)❑ REPLACE SUPPLY(RS) <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) El VENT SOIL(VS} <br /> VACUUM EXTRACT(VE) OTHER(OT) <br /> z co nT a mr AA-1 O n Wi be Y�V e S 'I-t C��'} 2 GL r L d „�,�.y�� _' <br /> to,,� 4i u res P b A s <br /> HSC Q$(BAQ, <br />