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D. <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE,ONLY <br /> REPORT BEEN FILED 7 <br /> YES NO YES NO 1 HEREBY.CERTIFYTHAT 1.HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> a <br /> DISTRIBUTION.SHOWN ON.THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM, <br /> REPORT DATECASE 1 <br /> r SIGNED DATE.: <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> w REPRESENTING EDOWNER/OPERATOR r REGIONAL BOARD COMPANY OR AGENCY NAME <br /> gLOCAL AGENCY Q OTHER i�eC�� C.}Q-. } c��,�, ��1 ��"^- •^� <br /> ADDRESS c{!�-�r/`L/ � �� 1 D�Y� -S- o} e' C/4 c7_5 <br /> 3 STREET CRY STATE ZIP <br /> J NAME ;I � �� � "•� CONTACT PE SON ,(� PHONE /' (� <br /> z P �' UNKNOWN DL)u �5 1. 1 J �YJ)(O5 / i .1 <br /> COL ADDRESS sp p 1.1 t'r z� fi 1 Site 1 b O, S a-c�^a nu�vtc, C r ` is Se) ' <br /> STREET CRY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR � O_(� f�-� PHONE )34 3 -i�3 <br /> U <br /> ADDRESS �� ��CCG-L� ��D G��• V - � �� <br /> 2 /' SS �G <br /> w STREET CRY COUNTY ZIP <br /> CROSS STREET <br /> /1/, C� � i �� r n CL, <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w Sct�1v �pl f4>Puu.Q b; eL4 <br /> w 6i REGIONAL BOARD U vPHONE <br /> af <br /> N (t) NAME QUANTITY LOST(GALLONS) <br /> WC�� t� Ft F-D l3� f�e L� u�� �C <br /> a J UNKNOWN <br /> m z (Z) <br /> :- <br /> U) Q <br /> UNKNOWN <br /> Z <br /> DATE DISCOVERED C�/j Q HOW DISCOVERED O INVENTORY CONTROL E::] SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> w / MI �ul 11 9D Y / r TANK TEST R <br /> TANK REMOVAL OTHER <br /> am DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPL I.. <br /> Q � <br /> 4 <br /> • UNKNOWN REMOVE CONTENTS XCLOSE TANK&REMOVE E]REPAIR PIPING <br /> cc <br /> w M D Y Y <br /> HAS DISCHARGE BEEN STOPPED 7 REPAIR TANK CLOSE TANK&FILL IN PLACE E�]CHANGE PROCEDURE <br /> U p, <br /> U) YES 0 NO IF YES,DATE v -7.1 3 a REPLACE TANK Q OTHER <br /> 0 IA D V V V <br /> � SOURCE OF DISCHARGE CAUSE(S) <br /> cra F TANK LEAK UNKNOWN 0 OVERFILL a RUPTURE/FAILURE a SPILL •r <br /> U O F--j PIPING LEAK a OTHER F CORROSION UNKNOWN 0 OTHER y <br /> N wa CHECK ONE ONLY (TI, <br /> O UNDETERMINED SOIL ONLY 0 GROUNDWATER 0 DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) QJ <br /> CHECK ONE ONLY Fd� <br /> wcn <br /> NO ACTION TAKEN Q PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED Q POLLUTION CHARACTERIZATION <br /> cr <br /> C O LEAK BEING CONFIRMED a PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> O Q REMEDIATION PLAN 0 CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) 0 CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) 0 EXCAVATE&DISPOSE(ED) 0 REMOVE FREE PRODUCT(FP) 0 ENHANCED BIODEGRADATION(IT) <br /> J ISEE BACK FOR DETALS) <br /> a Z <br /> 0 CAP SITE(CD) 0 EXCAVATE d TREAT(ET) PUMP 6 TREAT GROUNDWATER(GT)E] REPLACE SUPPLY(RS) <br /> Lu0 <br /> Q< ❑ CONTAINMENT BARRIER(CB) LJ NO ACTION REQUIRED(NA) 0 TREATMENT AT HOOKU (HU) a VENT SOIL(VS) <br /> a VACUUM EXTRACT(VE) OTHER(OT) ) "ed4 d,�� � <br /> z <br /> w �Lt%'G�✓"�ti�.�`� '�' -, 1 �I�✓w 7(� � <br /> (��((Jp(� Cf ^ <br /> 0 <br /> O <br /> U <br /> HSC os(89D) <br />