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- T i <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE RFEPvr,: ' <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> 0 YES NO REPORT BEEN FILED 7 YES [:] NO THEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TOTHE <br /> DISTRIBUTON SHOWN ON THE INSTRUCTION SHEET ON THE SACK PAGE OF THIS FORM <br /> REPORT DATE CASE <br /> J, SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNA��TU••Rc <br /> REPRESENTING CI, OWNFRlOPERATOR REGIONAL BOARD COMPANY OR AGENCY NAME <br /> C, LOCAL AGENCY jj OTHER <br /> w - <br /> rr <br /> ADDRESS y�/7 yj.� /��'J f}/� ` Q <br /> 6 ✓ STREET f. /�Z 1/ N Per Cr" ��vGt ()!V STATE f�dA <br /> k„ NAME CONTACT PERSON PHONE ` <br /> w ( ! <br /> vl 7r1 UNKNOWN <br /> a ADDRESS <br /> u <br /> STREET Cm STATE �a <br /> �:ACI'_I Y NAME(IF APPLICABLE) OPERATOR PHONE <br /> < ADDRESS <br /> TOL r /52)L-- STREET-JA(/k--�L//VE /I I/ C11Y /Z V!V COi1NTY 0&-A Y <br /> CROSS STREET <br /> LOCA'AG=_NCY AGENCY NAME CONTACT PERSON PHONE <br /> c') 6�11t"pjfywma�t <br /> zww9 REGIONAL HOARD PHONE <br /> 4 <br /> {I} NAME QU.ANTITYL057(GA'_LCNSI <br /> w o <br /> U . <br /> NsEJ <br /> ° (z) - -- - <br /> �z <br /> DATE DISCOVERED HOWDISCOVEREDINVENTORY CONTROL �] SUBSURFACOE��MONITORING <br /> ,, /!�'�.fC NUISANCE CON'DIT'ON3 <br /> w <br /> v wl 40:_7_0 V YI r I_� TANK 1E57 u TANK REMOVAL ® CTHER 5�7rWtC J) rc JA[A PIPE F <br /> m DATE DIS:HARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> d u u1 p ❑ rI r UNKNOWN REMOVE CONTENTS CLOSE TANK&REMOVE �`-� REPAIR PIP:I G <br /> w <br /> O <br /> HAS DISCHARGE BEEN STOPPED 7 0 REPAIR TANK CLOSE TANK S FILL IN PLACE CHANGE PRQCEDGR=_ <br /> U <br /> o YES F] NO IF YES,DATE M M o CII Y Y M REPLACE TANK OTHERi- <br /> L,3 SOURCE OF DISCHARGE CAUSES) <br /> IT a TANK LEAK UNKNOWN O OVERFILL RUPTUArcrFAILURE 1� SPILL <br /> 6 v ❑ PIPING LEAK 17 OTHER 0 CORROSION UNKNOWN OTHER <br /> w w CHECK ONE ONLY <br /> N a <br /> a <br /> U UNDETERMINED SOIL ONLY GROUNDWATER ❑ CRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED F7] POLLUTION CHARACTERIZATION <br /> a LEAK BEING CONFIRMED F PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> N <br /> v CASE CLOSED CLEANUP COMPLETED OR UNNECESSARY) n CLEANUP UNDERWAY <br /> i n REMEDIATION PLAN � { Y) <br /> j CHECK APPROPRIATE ACTION(S) EXCAVATE a DISPOSE(ED) a REMOVE FREE PRODUCT(FP) ENHANCED DIO DEGRADATION(I <br /> J ` ISEE B�Gr f(Al f�*�4S] <br /> a Z CAP SITE(CD) EXCAVATE&TREAT(ET) r PUMP 3 TREAT GROUNDWATER IGT) REPLACE SUPPLY(RS) <br /> ❑ O <br /> Li <br /> w� <br /> 5 <br /> C) '� CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) F7 OTHER(OT) <br /> r <br /> z <br /> w <br /> 1 <br /> D <br /> U <br /> RCC as ra�c, <br />