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{ 4r <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED REL ASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES F(}REQ AL AGEiVCY U5E`OhIIY <br /> REPORT BEEN FILED 7 <br /> ❑ <br /> YES NO ❑ YES ❑ NO 1 HERE ."CE THAT HAVE DI5TAIBUTED THIS INFORMATION ACCORDING TOTHE <br /> REPORT OnrE DISTR 18 TION SHgWN ON 7NE WSTRUC7)DN SHEET ON THE BALI(PAGE OF THIS FORAh <br /> //'�� Q CASE s - . <br /> D �NI 0 4 Y SnNED ` <br /> NAME OF INDIVIDUAL FILING REPORT DA <br /> PHONE NA <br /> .�e�v os�n�ok4 (2a ) Alm -ops c � <br /> REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NA E <br /> RLOCAL AGENCY ❑ OTHER <br /> Ix ADDRESS ff <br /> SC>4k �t�l FjDOr �t '�4a C14Q '�Z <br /> CRY STATE <br /> 1 NAME CONTAC PERSON_ PHONE ziv <br /> z ��l � L ❑ UNKNOWN <br /> a <br /> a ADDRESS <br /> y 4 <br /> W <br /> cr <br /> CRY STATE <br /> FACILITY NAME(IF APPLICABLE) STREET is <br /> OPERATOR PHONE <br /> O �-1r <br /> a ADDRESS <br /> (3ZE CorrcJ <br /> L �* 6-u ��Y 5�S uth qs3�o <br /> y CROSS STREET <br /> % �� IP <br /> ro A <br /> z LOCAL AGENCY <br /> z�, AGENCY NAME CONTACI PERSON PHONE <br /> w (2rR)�41a 5-033s <br /> nW Cu- <br /> REGIONAL BOARD PHONE <br /> Un) ( ) <br /> zo NAME QUANTITY LOST(GALLONS) <br /> Lua <br /> UNKNOWN <br /> 2 <br /> y <br /> ❑ UNKNOWN <br /> PATE DISCOVERED HOW DISCOVERED <br /> * ❑ <br /> w INVENTORY CONTROL ❑ SUBSURFACE MONITORING F-1NUISANCE CONDITIONS <br /> `BMs -+lu� �oI of �r ❑ TANK TEST TANK REMOVAL E:] OTHER <br /> cl <br /> DATE DISCHARGE BEGAN METHOD LISED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> } M o r UNKNOWN ❑REM VE CONTENTS CLOSE TANKS REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED Z ❑REP UR TANK ❑CLOSE TANK d FILL IN PLACE ❑CHANGE PROCEDURE <br /> nlg� YES E:] NO IF YES.DATE (}] (� I l�� r•fir ❑q CE TANK ❑OTHER , <br /> SOURCE OF DISCHARGE �+a� �-'MI CAUSE(S) <br /> G LU <br /> wa ❑ TANK LEAK UNKNOWN ❑ OVERFILL E::] RUPTURE/FAILURE ❑ SPILL <br /> O El PIPING LEAK Jrr-❑� OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> LU wa CHECK ONE ONLY <br /> ca UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINK NG WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Z ❑ ND ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTIQN CHARACTERIZATION <br /> cr <br /> U�w; LEAK BEING CONFIRMED <br /> ❑ ❑ PRELIMINARY SITE ❑ POST CLEMIUPMONITORING iNPROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTIONS) E:] EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> 4 <br /> p g <br /> C:3 (ME BACK Faq OETA�CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Lua F7CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) C] VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> c, <br /> `��c.. r1��►c. ck.,�t.c� c�twl`' a f C.�-a w��.a�-L ,� c� ,�u t�,� fQ,;� v`�L� <br /> nRl I <br /> Tftf"0 GM <br /> Hsc as 4a" <br />