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1.016. <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATIO,IT REPQR ' ' <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES .FOK.LOCAIL AGENCY MSE ONLY <br /> REPORT BEEN FILED? <br /> ❑ YES NO ❑ YES NO i f1EREW CE9MYTHAT(HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE: <br /> OISTRIBU pN sOWlON T,I 1pl6TAl SHWA�V kTHF�K PAGE OF FDRM <br /> REPORT DATE CASE s <br /> NAME OF INDIVIDUAL FILING REPORTyy�� PHHONE a SIGNATURE <br /> m CJC.- 1 (sio ) O,Y1 s <br /> w <br /> REPRESENTING <br /> _tR:OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> g ❑ LOCAL AGENCY ❑ OTHER E <br /> s CpMpR <br /> q y <br /> ADDRESS P ®• Box scoq °�r f-'V R*1DAJ C4 7�y,YJ fl,7 -"O09 <br /> ,. STREET CITY STATE ZIP <br /> J NAME CON TACT PERSON�/ TPNE <br /> � CNL=r�ON pAQQIICT3 Cf�MP�I�� ❑ UNKNOWN <br /> z /URf'TT RvAl �� ) <br /> a a ADDRESS <br /> ul <br /> Al,fox 3460y S41f R4Mo4/, �� 9ySB3-D�oy <br /> STREET CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> C F—Y A) V A ' 9`/i �N E A E t o ) 3 -.zzYi <br /> ADDRESS <br /> 9.3(o Al- NA1 Z41vE t aD i S-4A/ J04,0811,V g5ZAJO <br /> W STREET CITY COUNTY ZIP <br /> t= CROSS STREET <br /> cn <br /> kooil - p b <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> W Si�i>1/ ✓ORQv»V&ve✓Ty PwOLIL f��A1T// SFR✓ICES ,t;¢/e Tip ✓ENA (:t09)J/&f 0333 <br /> w w REGIONAL BOARD PHONE <br /> a a 253%g133 <br /> LU (�) NAME QUANTITY LOST(GALLONS) <br /> o UAILF d AfftUWE- UNKNOWN <br /> Q J <br /> U) <br /> Z (2) <br /> us <br /> UNKNOWN <br /> = DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 0.1 o Y Y ❑ TANK TEST 54 TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M D Y y UNKNOWN E]REMOVE CONTENTS CLOSE TANK&REMOVE F-]REPAIRPIPING <br /> HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> S2 YES ❑ NO IF YES,DATEoml M 1 0 o r v ❑REPLACE TANK ❑OTHER <br /> 0 Lu SOURCE OF DISCHARGE CAUSE(S) <br /> ow ❑ TANK LEAK �UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> y v ❑ PIPING LEAK ❑ OTHER ❑ CORROSION 39 UNKNOWN ❑ OTHER <br /> w wa CHECK ONE ONLY <br /> U ❑ UNDETERMINED ><SOIL ONLY ❑ GROUNDWATER ❑ 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 E::] POLLUTION CHARACTERIZATION <br /> D w ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U REMEDIATION PLANCASE CLOSED(CLEANUP COMPLETED OR UNNECESSAR <br /> ❑ Y) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> J (SEE SACK FOR MARS) X"y <br /> a z <br /> w� ❑ CAP SITE(Cl ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)E::] REPLACE SUPPLY(RS) <br /> I- <br /> w a r-1CONTAINMENTBARRIER(CB) ❑ NO ACTON REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) E:] VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) <br /> 0VE-R£1CIc.Av-A1)vw oF vseb OIL- IMPRC7Eb Sott, 'TO 13£ PEkFokwtuD <br /> ACL.Oa41,,1b T© lkPPROvQq Cpft�!keC'pVr= 4!C'CION ?L" �TpvutS•rON€� I'.Z�^�lo' <br /> 8 <br /> HSC 05(aW <br />