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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EM ERG CY SERVICES <br /> REPORT BEEN FILED FQp LOCALAGENCY lJSE QNLY <br /> F-1 YES VO ? NO .1 HERE8Y CEFMFYTHAT E HAVE DISTRIBUTED THIS INFORMATIOD)ACCOd�DING;O THE <br /> YESE�j <br /> REPORT ATE DlSTRISU SHOWN ONT}iEINSTRUCTION SHEET 0NTHE$AGKPAGEOFTHISFORM <br /> CASE III <br /> ! <br /> y [ ' g <br /> OATE. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE v SIGNATURE <br /> O REPRESEry���NN G COMPANY OR AGFY�NAME gC OWNERIOPERATOR REGIONAL BOARDLOCAL AGENCY OTHER S H <br /> w <br /> ¢ ADDRESS <br /> A 0, sox � a G S7 G/�' - CA <br /> STREET STATE <br /> J NAME ilp <br /> y}�� CONTACTPERSON PHONE <br /> Z Q ! . ` UNKNOWN '� { <br /> CL CL <br /> DOR <br /> A�-E `l� V �J i6/scpa-1% • Q?� G VVV ,,-zo .. C R- 956 7 <br /> l STREET CITY STATE zip I <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o <br /> q ADDRESS <br /> w (ao ,. f GREET <br /> r j CROSS TREET COMM <br /> L � <br /> z LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w <br /> Lt. <br /> i3�1 REGIRONAL�BOARD PHONE 1 <br /> c 8 ! J <br /> Lu (�) JJqql!,,., NAME QUANTITY LOST(GALLONS) <br /> UNKSIOW N <br /> ! ❑ UNKNOWN <br /> z DATE DISCOVERED /%} HOW DISCOVERED ❑ I NTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lu <br /> 3 a LiTANK+ r r ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> r <br /> a DATE DISCHARGE BEGAN i METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Y M u o o r r [o UNKNOWN ❑REMOVECONTEN�S CLOSE TANK REMOVE ❑REPAIR PIPING <br /> Q <br /> w <br /> p HAS DISC RGE BEEN STOPPED? a REPAIR TANKS Q CLOSE TANK a FILL IN PLACE ❑CHANGE PROCEDURE <br /> w <br /> o YES ❑ NO IF YES,DATE M G `�o o DI ? l r ❑REPLACE TANK ❑ OTHER <br /> La vj SOURCE OF DISCHARGE CAUSE(S) <br /> a TANK LEAK UNKNOWN OVERFILL ❑ RUPTURElFAILURE SPILL <br /> y V ❑ PIPING LEAK OTHER ❑ CORROSION ❑ UNKNOWN OTHER <br /> i <br /> U,w CHECK ONE ONLY } <br /> v ❑ UNDETERMINED OIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER ,'(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED:: POLLUTION CHARACTERIZATION <br /> Lu <br /> N ❑ LEAK BEING CONFIRMEDRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN VASE CLOSED(CLEANUP COMPLETED OR UNNECESSAA <br /> Y}' � CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE a DISPOSE(ED) REMOVE FREE PRODUCT(FP} ENHANCED Bro DEGRADATION(IT) <br /> (SEE OA"RA OETALM <br /> W p ElCAP SITE(CD) EXCAVATE b TREAT(ET) PUMP 6 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) OTHER(OT) U <br /> D fi z� 11Ln - <br /> yi <br /> Ila � <br /> 1{ os t�q <br /> - A <br />