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a <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS OFFICE OF EMERGENCY SERVICES <br />........ ...... <br />FOR LOCALAGENCY..USE.DNLY.........,............''..''. <br />........................... ................. <br />REPORT BEEN FILED? YES NO DYES [j!rNO <br />EV, <br />........... NaT <br />13 IN. RMATIM: <br />. FO EQCAE RSD ........... ...... <br />T C!4$ <br />...... ..... ...... <br />E . .:. . <br />N.4 ANt).Wp ��i����.i..; <br />REPORT DATE <br />E8 <br />/ 0 Qd6D, 9y]�� <br />.... . .................. . . .. ................. ..... . .... ... <br />....................... ....................... <br />.............. ...... <br />......................... ... <br />...... .... . ........... <br />.1 .1 <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATO <br />�my <br />j <br />0 <br />w <br />REPRESENTING OWNERIOPERATOR Q REGIONAL BOARD � <br />COMPANY OR AGENCY NAME <br />a77F� <br />12rLOCALAGENCY OTHER <br />6 <br />[ADDRESS <br />yl,5- IV 519-,V kJWQ0/A/ S-77 952 -62 - <br />STREET CITY STATE ZIP <br />w <br />NAME <br />CONTACTPERSON <br />HONE <br />9)�- <br />E] UNKNOWN <br />?,POIL- I <br />40 C) 7191(d <br />z <br />Ra <br />M <br />M <br />ADDRESS <br />2?6 3 i�i V6 So 17ZF 360 /moi 04/0 <br />Crry STATE ZIP <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />PHONE <br />z <br />?, p (0/(-- <br />ADDRESS <br />CITY COUNTY ZIP <br />CROSS STREET <br />1 05-1 bq-1v'5- <br />Z <br />z I <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />I- w <br />z <br />W <br />WZ <br />w <br />REGIONAL BOARD <br />PHONE <br />IL <br />:E <br />NAME QUANTITY LOST (GALLONS) <br />Air Eg-111INKNOWN <br />(2) <br />UNKNOWN <br />W <br />DATE DISCOVERED <br />HOW DI FRED INVENTORY CONTROL SUBSURFACE MONITORING E] NUISANCE CONDITIONS <br />� 2 <br />-1 �o -1 (9yl 0 J <br />5ZTANK TEST F TANK REMOVAL OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />MI MI DI DI Yl yj 'UNKNOWN[:] <br />[TZrREMOVE CONTENTS r-� REPLACE TANK CLOSE TANK <br />0 <br />F-� REPAIR TANK REPAIR PIPING CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED? <br />O'YES E NO IF YES, DATE () q'Mll��Dj '�Dl qYl K) <br />E] OTHER <br />MI Y <br />L <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />TANK LEAK � UNKNOWN <br />F7OVERFILL O RUPTUREIFAILURE SPILL <br />rJ <br />PIPING LEAK F OTHER <br />F-� CORROSION UNKNOWN F OTHER <br />w Lu <br />CHECK ONE ONLY <br />UNDETERMINED E::] SOIL ONLY 0 GROUNDWATER Ej DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />w <br />w <br />Q <br />NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SU13MITTED Ej POLLUTION CHARACTERIZATION <br />M <br />MR <br />co <br />F7 LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br />F--1 REMEDIATION PLAN F--] CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) F7 CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTION(S) F --j EXCAVATE & DISPOSE (ED) REMOVE FREE PRODUCT (FP) ENHANCED BID DEGRADATION (IT) <br />(BEE .KFORDEWM <br />z <br />Lu Q <br />-1 EXCAVATE & TREAT (ET) rukp &TREAT GROUNDWATER (Gl) REPLACE SUPPLY (RS) <br />F_j CAP SITE (CD) F F <br />Q $i <br />� CONTAINMENT BARRIER (CB) 0 NO ACTION REQUIRED (NA) TREATMENT AT HOOKUP (HU) 0 VENT SOIL (VS) <br />Ej VACUUM EXTRACT (VE) OTHER (OT) <br />��, 5�� 6OC-10 ya-0-ZZ-)- 04?77 <br />�����z <br />w <br />42a 7t <br />0 <br />muw(11/89) <br />