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UNDERGROUND STORAGE TANK UNAUTHORIZED REL (Ei �/CONAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EME4GENCY SERVICES FOR.LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 ;1 HEREBY:CERTIFY THAT 1.HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ YES NO C YES NO <br /> DISTRIBUTICN SHOWN ON THEWSTRUCTION SHEETON THE BACK.PAGE OF THIS FORM_ <br /> REPORT DATE <br /> 74 ,D rA MI�LJ.� E s <br /> :9 <br /> : <br /> DATE. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> GY' P!� S (�cf) 4d-033 <br /> w REPRESE ING ❑ OWNER/OPERATOR REGIONAL BOARD I COMPANY OR AGENCY NAME <br /> LOCAL AGENCY ❑ OTHER p 4 S f--{ <br /> ¢ ADORES �V I"l fDt. 's1�.K 1 1 Y e X15 I <br /> `7� STREET q CT' STATE ZIP <br /> Lu NAME CONTACTPERSON � PHONE <br /> Z U ! ❑ UNKNOWN r S �V✓� �S (4I1 5) 7q <br /> q� <br /> fn <br /> a k. <br /> a ADDRESS <br /> (/�� q <br /> ¢ M4 w k esk, 5: 3'5 f Fi oo►� �m 644Rra nu� STATE • -?c <br /> ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> N�c_KeYs� c ql� ) - 3s1 <br /> a ADDRESS � ^ c-�^ -^{' Q� <br /> N. sett,11 �OQ ut S'cc.K�1 �1 Va[-(�{U L i� WZ�/L <br /> w STREET CITr COU TIP <br /> ~ CROSS STREET V\' <br /> N <br /> L)I wI Yn I <br /> O LOCALAGENCY vAGENCY tiWE CONTACTPERSON PHONE <br /> z cn <br /> ��c v1 CaYl �lS `MG✓ M2�' S (90 )469-0331- <br /> Lu <br /> as REGION PHONE <br /> V cd kw Q <br /> f <br /> y (1) <br /> CSI lNAME QUANTITY LOST(GALLONS) <br /> LU -aW co✓Y44Lp p-/ �! <br /> UNKNOWN <br /> co O (2) n1J I +(} <br /> U)Z I e p IC UWI lI(��' O��I�AE/GV� - R)RA 49 L ��� JNKNOWN <br /> z DATE DISCOVERED HOW DLSCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE COND ONS <br /> Lu <br /> z Q /� <br /> w OMI U M� �v o� �r r [:] " TEST ❑ TANK REMOVAL OTHER L4 b � e,5 Uf', <br /> OI^ <br /> a <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> w uo r v <br /> UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK b REMOVE ❑REPAIR PIPING <br /> >O HAS DISCHARGE BEEN STOPPED 9 E]REPAIR TANK ❑CLOSE TANK S FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> `) ❑ YES NO IF YES.DATE ❑REPLACE TANK ❑ OTHER <br /> C, I M� of yl r <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> j a ❑ TANK LEAK Ce UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> W v ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ErUNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> Na <br /> v ffrUNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wco <br /> ❑ NO ACTION TAKEN r7PREL.9IIVARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> crQ LEAK BEING CONFIRMED PRRELHIJARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN D CASE-OSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> (SEE BACK FCR WTA S) <br /> a Z ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Lu <br /> w a F-1CONTAINMENTBARRIER(CB) ❑ 40 ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> Z <br /> w �1( b e- �`e�L) �4:!rm i <br /> w �,-t v✓ e a-vtd e.X f E Lori Fav►�tva fi�,cs/1 as ►^�o vied <br /> U <br /> b --t'V C.p Q ro pV-tA� (� L)v HSC lcc 1'U Q <br /> 05 <br />