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Z-- 7.3 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMEAGEN SERVICES FOR LOCAL AGENCY t1SE ONLY '- <br /> REPORT BEEN FILED? .l HEREBY CERTIFYTHAT)HA TRIBUTED THIS'INFORMATIDN ACCOAOCNG TO THE <br /> YES NO YES Q NO <br /> OISTRIBUT ON SH $TRUCTION.SHEET.ON T t BACK PAGE'O .iHlS F M <br /> REPORT DATE ..CASE s <br /> M Y $ DATE <br /> NAME OF NDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> r <br /> ( 20?) 7Y-6336 <br /> m <br /> w REPR�ING OWNER/OPERATOR Ej REGIONAL BOARD COMPANY OR AGENCY NAME <br /> LOCAL AGENCY OTHER ""7 c <br /> ADDRESS <br /> i <br /> STREET J � I��L•/r GT' `�'/ �/ STATE ZIP <br /> w NAME CONTACT PERSON PHONE <br /> Z �'6MJ�SD l UNKNOWN Ci /�C ZOY J -rzzz- <br /> cc <br /> 0< ADDRESS <br /> y <br /> w <br /> 2 ITY <br /> STREET D � CO �d1 STATE Cf¢., IP <br /> FACILITY NAME(IF APPLICAB E) OPERATOR PRONE <br /> o io 405 i 7� c:v- <br /> a ADDRESS07 <br /> � Dw STREET CITY COUNTY <br /> 1= CROSS STREET <br /> y <br /> 46 Gtr- <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> rw <br /> w r ! V-" ¢�A 1 `) <br /> o — <br /> w REGIONAL BOARD PHONE <br /> uy (s) NAME QUANTITY LOST(GALLONS) <br /> v w � D/�j4 NKNOWN <br /> a0 t� <br /> r <br /> m {2} <br /> y UNKNOWN <br /> rDATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL S URFACE MONITORI NUISANCE CONDITIONS <br /> LU <br /> � DMI ��I � TANK TEST TANK REMOVAL OTHER r�,j�ct L��vtu ' d <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Q -710 w v i NKNOWN ❑REMOVE CONTENTS OSE TANK&REMOVE Q REPAIR PIPING <br /> HAS DIS RGE BEEN STOPPED 7 REPAIR TANK CLOSE TANK&FILL IN PLACE a CHANGE PROCEDURE <br /> 9YES E:] NO IF YES,DATE REPLACE TANK O OTHER <br /> MI e d r r <br /> SOURCE OF DISCHARGE CAUSES) <br /> w <br /> O TANK LEAK UNKNOWN OVERFILL RAILURE SPILL <br /> y U F-] PIPING LEAK OTHER 0 CORROSION NKNOWN OTHER <br /> Lu w CHECK ON Y <br /> a <br /> � UNDETERMINED Q SOIL ONLY Ej GROUNDWATER 0 DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> r LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ED POST CLEANUP MONITORING IN PROGRESS <br /> v <br /> in CASE CLOSED COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> REMEDIATION PLAN O Y) <br /> CHECK APPROPA TE ACTION(S) EXCAVATE&DISPOSE(ED) E::] REMOVE FREE PRODUCT(FP) Q ENHANCED BIO DEGRADATION(IT) <br /> Q Z S OEr" <br /> o p CAP SITE(C D) EXCAVATE 8 TREAT(ET) O PUMP&TREAT GROUNDWATER(GT)0 REPLACE SUPPLY(RS) <br /> aa CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) O TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) OTHER(OT) <br /> en <br /> r <br /> z <br /> w <br /> �D <br /> U - <br /> HSC 05(MO? ' <br /> i <br />