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i � C16 - <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR�OCAI 'AGEZIGYsUSE OP[LY <br /> REPORT BEEN FILED 7 - <br /> ❑ YES [� NO YES ❑ NO ,:HEREBY:CERTiFYTH117t HAVE,D[57RIBU7EDTHISIyFORMkT10N;ACCORDINGTOTHE: <br /> glSTRiBUTICN SHOWN ON THE INSTFtUGTK)N SHEET ON THE BACK PAGE OF THIS FORA( <br /> REPORT DATE CASE s ❑ <br /> t. <br /> Qd Z MI �a Q .S <br /> :;. :... <br /> NAME OF INDIVIDUAL FILING REPORT PHONE NATURE <br /> �Gr`� `caShLak� (ZA`t}4(vFs-o33S <br /> w REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD C�OM�PA+NY OR AGENCY NAMEcc <br /> LOCAL AGENCY ❑ OTHER �]C�L� Q Llls+� � C.`�U..�•�'y <br /> a ADDRESS <br /> cA - Qs2oz <br /> STREET CRY STATE ZIP <br /> J NAME A.x�tb 4�1�t��hoas� CONTACT PERSON PHONE <br /> co� � ` E] UNKNOWN �'v-awk cRoj in (209 41c5-8-fZ4 <br /> Ir <br /> aa ADDRESS <br /> 3 �_ �1u�� g-1-a�k�Q�, QA - 4szo3 <br /> STREET CRY STATE 21P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> z �cd F'o�d W Z A6 ka.Wo r- t 2Q�} q�1 -4Sn; <br /> OADDRESS82QO Kk. CITY <br /> w <br /> N CROSS STREET <br /> I <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> W ` <br /> wS �L� Css Z*Aucv-yall' <br /> w w REGIONAL BOARD PHONE <br /> C RW 0 C3 <br /> (1) / NAME QUANTITY LOST(GALLONS) <br /> LU <br /> 4 w [••;•as���n�! UNKNOWN <br /> CA m X (2) <br /> H ❑ UNKNOWN <br /> = DATE DISCOVERED HOW DISCOVERED CDINVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> /M �I , e Y v ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN - METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) I <br /> a UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK 6 REMOVE REPAIR PIPING <br /> w � u <br /> p HAS DISCHARGE BEEN STOPPED 9 E]REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> YES ❑ NO IF YES.DATE f M ' j Z DI ❑REPLACE TANK ❑ OTHER <br /> [O <br /> al SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> cc j ❑ TANK LEAK UNKNOWN ❑ OVERFILL RUPTURE/FAILURE ❑ SPILL <br /> v PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> I <br /> Lu w CHECK ONE ONLY <br /> U UNDETERMINEDDer SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER •(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFEGTEP} <br /> dHEck ONE ONLY <br /> w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERRATION <br /> VH ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY \�1 <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE A DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> tMBESOCKFORDETA A <br /> a x ❑ CAF SITE(CD) ❑ E <br /> O D XCAVATE 8 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)E] REPLACE SUPPLY(RS) <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REOUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ OTHER(OT) Q�VACUUM EXTRACT(VE) ❑ `I <br /> I'I r r[.[v' '�l CAT' S I T� a,S�3 c s 5r✓Li C r��� L1�L�I �?C. V`C q U(4"ccl cic4 k mlencl�l <br /> Hsc 050" <br />