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Alk <br />UNDERGROUND STORAGE " K UNAUTHORIZED RELEASE (LEAK) / CuNTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES... <br />REPORT BEEN FILED 7 <br />.... . <br />::FOR t OCAt `AGENCY USE;ONIY . ........... . <br />❑ YES NO ❑ YES ❑ NO <br />.:I HERESYCERIIFYTHAT.A: HAVE DISTRIBOTEDTH.S 1IFORMATION ACCORDING TO7HE <br />D IBU SHOWN ON THE )NSIAUCTIDN SHEEP ON THE SACK PAGE OF. THIS FORM <br />r <br />REPORT DATE <br />CASE N <br />' M M v <br />1 .7 <br />SIG ED DATE <br />. .:. .:.: <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE <br />m <br />z L. r,c2 <br />(SID <br />Lu <br />REPRESENTING � OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br />❑ LOCAL AGENCY ❑ OTHER �/ <br />w2 <br />w q L <br />ADDRESS ?'o, BOA 5004 San, -amofi , ch q*4 S193-8604 <br />STREET CITY STATE ZIP <br />Lu <br />NAME <br />CONTACT PERSON <br />HONE <br />z ¢ <br />rC i �i po u �rlthro O UNKNOWN <br />fmu <br />7510)42- 1305 <br />co da <br />Q <br />ADDRESS <br />P.O. Bax S004 Sa,n ke-un n� CA aLtls#3- ®"'� <br />STREETSTATE ZIP <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />PHONE <br />o <br />hCvrpil erylze. %gtIQ 'y1� Icgrw"N <br />© <br />IRD S <br />(%�) Lv+f3-55s-q <br />U <br />o <br />ADDRESS <br />`2-905 W. IIENutwUN flL.T tZ, STDCIcTOn! SHN lQR6tViN% qSlp+ <br />w <br />STREET CRY COUNTY ZIP <br />y <br />CROSS STREET <br />PLYKOVTA R.D_ <br />O <br />z <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />w z <br />SItN lDRa xin to S <br />Qy MARY <br />(MV 446 - 33 <br />w 6i <br />REGIONAL BOARD <br />PHONE <br />a <br />L",/ <br />E -u ©>t H m- <br />(91(o) A55-3)33 <br />W o <br />(1) NAME QUANTITY LOST (GALLONS) <br />Q J <br />UIwL eA E SOLI �t UNKNOWN <br />Z <br />7 — <br />//�� <br />Ate)) <br />y <br />❑ UNKNOWN <br />Z <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />Lu <br />Ml 1 M 8 0� v y <br />❑ TANK TEST ❑ TANK REMOVAL OTHER fj?jAj& RrM D V R L <br />m <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />M M D D Y y UNKNOWN <br />E:] REMOVE CONTENTS E:] CLOSE TANK & REMOVE ❑ REPAIR PIPING <br />Lu <br />p <br />❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED Z <br />Uo <br />YES ❑ NO IF YES, DATE <br />❑REPLACE TANK 'OTHER �t%Lp(CE fiPj 6 <br />M MI o o y y <br />w <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />j < <br />[7TANK LEAK NL UNKNOWN <br />❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br />y V <br />PIPING LEAK ❑ OTHER <br />❑ CORROSION I UNKNOWN ❑ OTHER <br />Lu w <br />IL <br />CHECK ONE ONLY <br />O <br />❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />s❑ <br />NO ACTION TAKEN F-1PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />DM;5 <br />❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />U <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br />J <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />(.SLE BACK FOR WTA") <br />Z <br />w <br />ED SITE (CO) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />2 a <br />❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) VENT SOIL (VS) <br />VACUUM EXTRACT (VE) �K OTHER (OT) Am- Smga 1 fal- <br />REPRQT+Ep RV-LC%C- F}TFLC'(S 50tL. ONLY, AJC FVtZT0Cj- A T)ON lift TlCiPATEA <br />FbR- 'Ttk15 'QcL rAc. Currtn} SAQ/ V5 Rj)D v- rmfEA?gL. riCTPo�S �1PPtY 'To <br />3 <br />A+ SzPA2itTc�R102 RELc�S�. �(� v c��"i', gS5e55YKI�.✓�`� uy1« Ip✓ <br />HSC 05 Iarem <br />