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i e -%L 1_4 <br />U <br />UNDER AGE T1117K UNAUTHORIZED RELEASE (LE____W <br />UNDERGROUND (LEAK) I CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />REPORT BEEN FILED ? <br />:FOR LOCALAGENMUSE ONLY*,.:-: <br />❑ YES NO E] YES >('No <br />...... <br />:.J.HEREErY, CERTIFYTHAT.I. HAVEDISTRIBUTO TH(SINFOAMATIoN AWAMG TO THEpIS <br />UTI SHOW TH INSTRUCTION :: SH O.N:. THE BACK PAGE OF <br />REPORT DATE <br />CASE s <br />OM �D <br />.j+' <br />..... .. 7t: <br />MI Y <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE pp .. .... <br />'RAIA- <br />w <br />REPRESENTING 0 OWNERI�PERATOR �[:] REGIONAL BOARD COMPANY OR AGENCY NAME <br />w <br />LOCAL AGENCY 0 OTHER_ <br />Iqlj a^ <br />cc <br />ADDRESSLJry f CA <br />%5$cdl�r E•Wcziq;z <br />STREETcrry STATE ZIP <br />Lu <br />co <br />NAME <br />ell <br />CONTACTPERS N <br />-z <br />PHONE <br />U5 �: <br />z cr <br />rpru 5" e;5 &�s v MsO 0 UNKNOWN <br />C A - <br />COL t<L <br />U) <br />w <br />ADDRESS <br />c-, ou P. P� Ac-ztjpp, 44ILL-S CA q1361 -q3lt <br />2v STREET CT Zoo <br />CITY STATE- ZIP <br />FACILITY NAME (IF APPLICABLE) 4OPERATOR PHONE <br />5Pr 6-AfooLNG 7,boljhj4,-FpmpK;kLs <br />LD <br />635 q 65- t456 <br />< <br />0 <br />ADDRESS <br />010UNTrzy CLur;-, bWo 610ck�o .64N jor7l <br />w <br />52b� <br />STREET CITY 9z <br />cc <br />5i <br />CROSS STREET <br />- _Rvcl e. <br />z <br />Lu (n <br />LOCALAG LTINCY AGENCY NAME <br />5, )�� <br />CONTACT PERSON <br />PHONE <br />Z <br />Lu 0 <br />W <br />inlw2n U146,ENVIF, <br />w Cu0 <br />0- < <br />REGIONAL BOARD I <br />0_C -01E&_ VALLEV <br />PHONE <br />Asiv &&TzE Li— <br />(71b)2_55-3115 <br />Lu <br />w <br />MIETWL <br />NAME QUANTITY LOST (GALLONS) <br />_FFqR-r-bV <br />z <br />< >✓ <br />- L Gf-ffc— UNKNOWN <br />c- <br />0 <br />U) <br />(2) <br />1 <br />UNKNOWN <br />z <br />w <br />DATE DISCOVERED <br />J <br />HOW DI COVERED TORY_ CONTROL rX SUBSURFACE MONITORING <br />INVENTORY NUISANCE CONDITIONS <br />2 <br />w <br />0.1 3 -1 o-1 0,1 2, <br />E:] TANK TEST ❑ TANK REMOVAL ❑ OTHER <br />;< <br />m <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />UNKNOWN <br />M -DD1y <br />l 1 1 1 1 l <br />❑ REMOVE CONTENTS [::] CLOSE TANK& REMOVE ❑ REPAIR PIPING <br />Lu <br />> <br />0 <br />0 <br />REPAIR TANK E] CLOSE TANK & FILL IN PLACE F__j CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED 7 <br />cl) <br />Ej YES E:] NO IF YES, DATE <br />D REPLACE TANK F-1 OTHER <br />ml mi .1 01 yl y <br />L <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />U) <br />cE-1 <br />TANK LEAK UNKNOWN <br />X <br />E] OVERFILL RUPTUREJFAILURE SPILL <br />0 <br />U) O <br />❑ PIPING LEAK F__j OTHER <br />❑ CORROSION x UNKNOWN ❑ OTHER <br />Lu w <br />CHECK ONE ONLY <br />L< <br />F__j UNDETERMINED ❑ SOIL ONLY GROUNDWATER [:] DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />z <br />w jR <br />NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTEDPOLLUTION CHARACTERIZATION <br />6 <br />a: , <br />cc P <br />:3 U) <br />d LEAK BEING CONFIRMED F__j PRELIMINARY SITE ASSESSMENT UNDERWAY E:j POST CLEANUP MONITORING IN PROGRESS <br />0 <br />F__j REMEDIATION PLAN F__] CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) F__j CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTION(S) <br />tSEE aAZ9 FOR DETALS) EXCAVATE& DISPOSE (ED) ❑REMOVE FREE PRODUCT (FP) F_� ENHANCED BIO DEGRADATION (11) <br />Ej <br />:5 z <br />0 p <br />W <br />El CAP SITE (CD) ❑ EXCAVATE& TREAT (ET) ❑ PUMP& TREAT GROUNDWATER (GT)E:] REPLACE SUPPLY (RS) <br />M <br />w < <br />a: <br />f-] CONTAINMENT BARRIER (CB) E] NO ACTION REQUIRED (NA) Ej TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />r-1 VACUUM EXTRACTIVE) F__] OTHER (OT) <br />F40e. 6v6+ -),m -10 V <br />g�jDlj'bocl"Eb 'COWh RA. ND <br />W <br />w <br />m <br />�g . <br />-2 ogt� <br />W NA) 4 2-n 3 --!!- (4) <br />7 fFj� 4,4V4, kruzi 73= <br />2 <br />0 <br />E2 LL�Nd til SITE iN <br />ty-TC-t-Tr-ot IAJPAtex- -jo De- JC�-�ntiIrte. - "' <br />