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4 <br /> cil- uqcl <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES 'FOR LOCAVAGENCY-USE <br /> REPORT BEEN FILED 7 <br /> 0 YES NO OYES O NO 1 HEREBY CMF..Y-THAT l:HAVE DISTRIBUTED.THIS INFORMATM ACCORDI#IG TOTHE <br /> 0IM18UTtON SHOWN CN THE W STRU CTION SHEET OPi THE BACK PAGE OF THIS <br /> REPORT DATE 1 //�� 1k CASE s MI 0 -1 U d ` r SIGNED . � l <br /> :.. a .. r,. .. .':> :. .'. ,.. ::,.' . . :�.;,:. :,:a DATE- .. <.-.. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> L4 (g-Sq4`I `��lra. '�' t�.%'�c-'`��► <br /> LOU REPRESENTIN E:3 OWNERfOFfaATOR 0 REGIONAL BOARD I COMPANY OR AGENCY NAME <br /> LOCAL AGENCY OTHER ��[r Cy,, �p. PLL b it G ti,& 1-41,sero, 4nV l r. [ea f- <br /> r ADDRESS S.i{ q <br /> ST CrrY tiJ z v STATE CA <br /> Lu NAME CONTACT PERSON TPHIONE <br /> m <br /> z¢ A r 6 r � UNKNOWN ) <br /> a s ADORW v N C( E 11 <br /> Lu <br /> STREET CRY STATE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> r t 1 <br /> ¢ ADDRESS <br /> w <br /> tic) STREET ` ! �/r� �V GT' -1 V 1.-.V+_ CA ,•UH, T P <br /> y CROSS STREET 11� <br /> Orin ` xO A-V`nLk-e-- <br /> p LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> 2 y <br /> W� Sar: utnCO n 611 5erutcf5 a.r��` <br /> w w REGIONAL BOAAD <br /> PHONE <br /> t ) <br /> y {7) NAME QUANTITY LOST(GALLONS) <br /> wO <br /> tu <br /> f%t Q _ UNKNOWN <br /> fig. m 9 <br /> �} z <br /> N- a UNKNOWN <br /> i <br /> DATE DI{SCOVEREO '2,1 <br /> � HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING Q NUISANCE CONDITIONS <br /> 1 I { d <br /> 5.1 �+Q r 7 <br /> r ❑ TANK TEST TANK REMOVAL Q OTHER <br /> a DATE DISCHARGE BEGAN MMOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> r� Q UNKNOWN REMOVE CONTENTS t%GLOSE TANK d REMOVE Q REPAIR PIPING <br /> `vl > HAS DISCHARGE BEEN STOPPED 4 Q REPAIR TANK Q CLOSE TANK a FILL IN PLACE Q CHANGE PROCEDURE <br /> o YES 0 NO IF YES.DATE o r r REPLACE TANK 0 OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> O TANK LEAK UNKNOWN OVERFILL RUPTUREIFAILURE Q SPILL <br /> a <br /> U Q PIPING LEAK OTHER CD CORROSION UNKNOWN Q OTHER <br /> U,w CHECK ONE ONLY <br /> H 4 <br /> UNDETERMINED 0 SOIL ONLY CD GROUNDWATER 0 DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w NO ACTION TAKEN 0 PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMEETED POLLUTION CHARACTERIZATION <br /> 2 <br /> r a LEAK BEING CONFIRMED Q PRELIMINARY SITE ASSESSMENT UNDERWAY 0 POST CLEANUP MONITORING IN PROGRESS <br /> O REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE d DISPOSE(ED) Q <br /> pptc e�cacra,DETA�dI REMOVE FREE PRODUCT(FP) Q ENHANCED BIO DEGRADATION(IT) <br /> � � <br /> n Q CAP SITE(CD! EXCAVATE 6 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)Q REPLACE SUPPLY(RS) <br /> ul <br /> CONTAINMENT BARRIER(CB) NO ACTION REOUIREO(NA) ❑ TREATMENT AT HOOKUP(HU) Q VENT SOIL(VS) <br /> F-1 VACUUM EXTRACT(VE) Q OTHER(OT) l <br /> R'eCAU L ew o 4— -t c l Q lr�c�E C p��-e� r`4 kex- 5�[� a.SSe-c S 1 P�.��' 15 n ceded <br />