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Ah C)9 u"4« <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> FOR.LOCAL-AGENCY USE ONLY <br /> REPORT BEEN FILED 7 <br /> ❑ YES NO YES ❑ NO I HEREBY CERTIFYTHAT i HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> REPORT DATECASE/ DISTRIBUTION SHOWN CN THE WSTRUCTION SHEET ON THE BACK PAGE OFTHIS FORhL <br /> SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> fi ! r az or 6?b ) 4'b�'3At✓z <br /> REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME J <br /> OLOCAL AGENCY ❑ OTHER Scz/ V <br /> w <br /> ¢ ADDRESS p <br /> �30 y � k)�kj fq-t Le - <br /> $TPfEr cm SIAM np <br /> w NAME A {��H^ GONTACTPERSON PHONE <br /> /11' I UNKNOWN v 1)G��i`-G�W�/ cab9 'a-,?7d 7 <br /> O < ADDRESS <br /> ¢a k�D75CvtMJ�7 �.O, Eo� 3 `)o. �c Skin C/� q_6�O � <br /> cm <br /> FACILITY NAME 1p NAME(IF APPLICABLE) OPERATOR PHONE <br /> WI r9 C�- Jia-Z�� �aaq) �6a-87o <br /> ¢ ADDRESS <br /> . m si, 'Sfa��' - <br /> CROSS STREET <br /> couK np <br /> oRG Aire, <br /> z LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> 5 �a�1 �occ - 4, LH D <br /> w Z REGIONAL BOARD <br /> a a / , , C 13PHONE <br /> (�(J <br /> E ( ) <br /> F <br /> NAME <br /> tip Ii V QUANTITY LOST(GALLONS) <br /> rv �'" �a. UNKNOWN <br /> m O> (2) <br /> m Z �78Ef L?CGa r ` UNKNOWN (� <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w <br /> r ❑ <br /> TANK TEST TANK REMOVAL E:] OTHER <br /> QDATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> wH o v UNKNOWN REMOVE CONTENTS 754CLOSE TANK&REMOVE E:]REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK E FILL IN PLACE rI CHANGE PROCEDURE ' <br /> o ❑ / G�� /, Cr �v Y ❑REPLACE TANK ❑ OTHER <br /> `9 YES NO IF VES,DATE U <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢j ❑ TANK LEAK Y UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> w O ❑ PIPING LEAK �❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> ya CHECK ONE ONLY <br /> O Z ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w� NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLANSUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ¢r LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O w ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLE MOOR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPPROPRRIIATE�CTION(S) EXCAVATE d DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> < CD <br /> 0 0 ❑ CAP SITE(DID) EXCAVATE 8 TREAT(ET) ❑ PUMP d TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> < ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL NSI <br /> ❑r VACUUM EXTRACT NE) OTHER(OT) <br /> O <br /> Z yam✓�..c/ - J "D c/V� <br /> �� • NSC 05169% <br />