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n <br />` ,7s -uv -�, <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAM(SI��E�ii; <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />IrOR LD�A� AGENCY USE ONLY'w <br />REPORT BEEN FILED 9 <br />❑ YES J NO ❑ YES ( No <br />.114EREBYGERTIFYTH4TI HAVE:DISTRIBU7EDTHISINFORMATIONACCORDING TOTHE <br />.DtMIBUTlON SHOWN ON THE INSTRUCTION SHE ON $ACWPAC T i� G:; <br />s <br />REPORT DATE <br />CASE i <br />-I mi 2)d tel. `' 4 Y <br />SIGNED DATE <br />NAME QF INDIVIDUAL FILIWIJREPORT <br />PHONE <br />ilk--- <br />SIGNATURE <br />m <br />o <br />� <br />cc <br />REPRESENTING ❑ REGIONAL BOARD <br />WNER/OPERATOR <br />COMPANY OR AGENCY NAME <br />ARCO <br />R <br />R <br />❑ LOCAL AGENCY OTHER <br />cc <br />n <br />ADDRESS �(r go,)Oa -+ <br />(,& d <br />. O 0 -" STREET �V CITY STATE ZIP <br />w <br />NAME a �� <br />(� <br />CONTACT PERS N <br />PHONE +� c� <br />"S ii� <br />z <br />Q, Cp f'(ok� W ❑ UNKNOWN <br />!O T <br />O(L Qa <br />w <br />ADDRESS <br />2 <br />STREET CITV STATE ZIP <br />o <br />FACILITY NAME (IF APPLICABLE) <br />sq so <br />OPERATOR <br />Ea uaati� , ZsaacsrJ n, <br />PHONE <br />(ao9) b 4% 16 <br />U <br />ADDRESS (�y� , <br />, r��et() <br />STREET �`��. CITY v Wl•� lC/V�. C.OUNTY�'1`C±"rLIP <br />w <br />tc: <br />CROSS STREET <br />C) <br />�ry <br />z`� <br />h w <br />LOCAL AGENCY AGENCY NAME <br />%a z aq <br />CONTACT PERSON <br />PHONE <br />w w <br />a. <br />REGIONAL BOARD <br />PHONE <br />w <br />Z w <br />NAME QUANTITY LOST (GALLONS) <br />' ❑ UNKNOWN <br />Q J <br />t <br />V (� <br />co 2 <br />(2) <br />D — <br />❑ UNKNOWN <br />Z <br />DATE DISCOVERED O� G <br />HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING NUISANCE �CO 1TIONS <br />C,V �� ('L <br />`'MI `— M o ` o " Y� Y <br />E:] TANK TEST ❑ TANK REMOVAL OTHER rj*WQ/tl <br />a <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOPDISCHARGECPPLY) <br />�M o �v� v ❑ UNKNOWN <br />REMOVE CONTENTS OSE TANK 8 REMOVE REPAIR PIPING <br />❑ ❑ E] <br />0 <br />❑ REPAIR TANK CLOSE TANK & FILL IN PLAE ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED? <br />0 <br />YES ❑ NO IF YES, DATE[M a MI a o -t -L v <br />v ❑ REPLACE TANK OTHER v <br />-a <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />Q CD <br />U <br />❑ TANK LEAK E:] UNKIJOWN <br />❑ OVERFILL ❑ RUPTURE/FAILURE SPILL <br />❑ UNKNOWN OTHER( <br />❑ PIPING LEAK OTHo'- <br />❑ CORROSION <br />N wa <br />CHECK ONE ONLY C, ` ,_ C( NA- O N <br />•,V <br />tai � <br />E] UNDETERMINED SOIL ONkY ❑ GFiDUADWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />I. - <br />ca <br />❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />Q � <br />:3;5 <br />y <br />❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />❑ REMEDIATION PLAN &;;r CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />IEEE BACK FOR DETALS) <br />a <br />00 <br />o <br />El CAP SITE (CD) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />w a <br />cc <br />❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUI ED (NA) ❑ TREATMENT AT P (H) ❑ VE N SOI S) <br />❑ VACUUM EXTRACT (VE) OTHER (OT) W <br />y <br />app a3G-a�n. Guy► �V �� ,ti ,s �ti\� 0.p �1►n,tjo <br />ucr. ns �AN01 <br />M'. K •A . bt^r4\e... <br />