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n <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMIERG SERVICES <br />TO I AL AGENCY . ..... . . .. .... ... ... <br />-AG ...... <br />USE <br />REPORT BEEN FILED? <br />F --j YES NO 7YESY NO <br />.,IMEREBY. CE.RT,I.,F.Y,.THATl::)iAVE-DISTRIBUTED ..THIS:INFORMATION ACCORDING. TO THE: <br />TION ETON THE BACK PAGE, OFTHIS FORK <br />::.DIM IBOTIOWSHOWN 0N.THE INSTRUr SHE <br />................. ..... <br />REPORT DATE <br />CASES....... <br />J <br />. .......... <br />Ml -1 4 �61 <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />10) <br />SIG <br />TURE <br />>- <br />m <br />w <br />R ED OWNER/OPERATOR F-1 REGIONAL BOARD <br />1( <br />COMPANY OR AGENCY NAME <br />R <br />LOCAL AGENCY 0 OTHER <br />9 <br />;aA 3 Ki r) Cwn-hA Yvlvp6qenta lip <br />cc <br />AbDAESS <br />3o4 e;. \jve-Ao&-Ave*jjA-Q- CA q5Zo'Z- <br />STREET crry STATE ZIP <br />w <br />NAMEomi <br />T <br />TACTPERSON <br />PHONE <br />W �: <br />z <br />KA0J oilawar OUNKNOWN I <br />-a" v\ D i I AW 0-1- <br />(2Dq ZI - LAI 2-7 <br />cc <br />00 < <br />U) EL <br />wmoele,,�� <br />ADDRESS <br />CA 5360 <br />q <br />3in <br />jasp�rNQ.,�� CITY STATE Ip <br />FACILITY NAME (IF APPLIdABLE) <br />OPERATOR <br />PHONE <br />W C, L, Q f �W,e, �4ftPl1v16tWaZM <br />I <br />(Zog Lgd- (o3L40 <br />Z <br />0 <br />DkaKli eA <br />ADDRESS <br />c? 52aa <br />LLJ <br />CITY COUNTY ZIP <br />CROSS STREET <br />O <br />LOCAL AGENCY AGENCY NAME CONTACT PERSON <br />PHONE <br />z <br />F- wi <br />z <br />w <br />ssc- envwcmmevv�t I-6j+k <br />(0)qb%-5q4j <br />w <br />REGIONAL BOARD <br />PHONE <br />a. <br />'Req6AW vAicra�v� X�v <br />W <br />NAME QUANTITY LOST (GALLONS) <br />I yl <br />aUNKNW <br />> <br />;� <br />C, OWN <br />_0 <br />U) 0 <br />> <br />z <br />(2) <br />O UNKNOWN <br />w <br />ZI <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ INVENTORY CONTROL E] SUBSURFACE MONITORING CONDITIONS <br />G NUISANCE <br />T �C <br />l <br />m <br />-I -DIYY <br />I I Q,� 3!2 lq <br />[:]TANK TEST ❑ TANK REMOVAL OTHER bo rL4kj <br />_ w -fs <br />la ixg <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL TAAT APPLY) <br />cc <br />DI DI Yl Yl :9 UNKNOWN <br />E] REMOVE CONTENTS LOSE TANK & REMOVE F --j REPAIR PIPING <br />Lu <br />0 <br />❑ REPAIR TANK F --j CLOSE TANK & FILL IN PLACE 0 CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED ? <br />0 <br />o <br />YES E] NO IF YES, DATEImD.b <br />i D � 1 d qlq <br />REPLACE TANK ❑OTHER <br />yYJ❑ <br />L <br />SOURCE OF DJSCHARGE CAUSE(S) <br />0 <br />cr:5 U) <br />SPILL <br />TANK LEAK UNKNOWN E] OVERFILL F --]SPILL <br />>01 <br />D < <br />0 0 <br />W <br />PIPING LEAK F--] OTHER ❑ CORROSION \5�1 UNKNOWN F--] OTHER <br />w w <br />(L <br />CHECK ONE ONLY <br />0 <br />UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER E] DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />z U) <br />w p- <br />F --j NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />:r?g <br />cc <br />=;5 <br />D co <br />F --j LEAK BEING CONFIRMED F --j PRELIMINARY SITE ASSESSMENT UNDERWAY E] POST CLEANUP MONITORING IN PROGRESS <br />F7 REMEDIATION PLAN If CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) F --j ENHANCED BIO DEGRADATION (IT) <br />(SEE BACK MR DUALS) <br />< <br />8 Z 0 <br />❑ CAP SITE (CD) F --j EXCAVATE & TREAT (ET) ❑ PUMP& TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />F_j <br />w <br />0 <br />w < <br />F --j CONTAINMENT BARRIER (CB) E] NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKU F-1 VENT SOIL (VS) <br />P (HU) <br />cc <br />VACUUM EXTRACT (VE) OTHER (OT)-R6fh� UDP -- ®ENT <br />❑ L- =1 <br />f2 <br />a!�56e-Sm erA- ts Y��w e-eid -I'l-LE-) o(0t*,-ml vka 4ha <br />Iw <br />7 <br />0 <br />nuc: w(aryl <br />