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04 u-05 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REP9FORR <br /> MERGENCV HAS STATE OFFICEOF EMEflGENCYSERVICES FOR LOCAL AGENCY.USE ONLY <br /> REPORT BEEN FILED? j HEREBY cER-nFYTHAT}HAVE DISTRIBUTED THIS INFORMATION ACCORDING <br /> -D YES NO ❑YES ❑ NO DISTRIBUTION SHOWN ON THE INSTRUCT ION SHEET ON THE BACK PAGE OF TH <br /> EPORTDATE ^ CASES <br /> C-1{ CIA <br /> I SIGNED SIGNATURE, DATE <br /> u 3u PHONE SIGNATURE, <br /> NAME OF INDIVIDUAL FILING REPORT <br /> Let ; 1` �3 r i S cap )4L.c'-3 ✓� <br /> a COMPANY OR AGENCY NAME I <br /> y REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD l3 <br /> - vp_ PN <br /> J2YlO TL C.-D <br /> � LOCAL AGENCY ❑ OTHER <br /> 2 ADDRESS <br /> zip30rG' osrREEr A 0-e, y' -ryyI/'•c'�.��. � S/A^T.E l <br /> � CONTACTPERSON PHONE <br /> NAME ell--)I <br /> � 1 . <br /> FS6 <br /> alwUNKNOWN <br /> L <br /> a ADDR SIlSLL /� -7 [� -}� q C7/✓CJ l i✓ ' �' �T/" ��1 01'vI <br /> STREET yyy...OPERATORPHONE <br /> FACILITY NAME(IF APPLICABLE) J1 <br /> b.J1 v (V/ al0 <br /> Ri11; es C <br /> ADDRESS r Sti"7�� Rya 15 <br /> 0 G S. ��( �-L�C-C'� / V cm couNTr e IP <br /> w <br /> a-i CROSS STREE <br /> CONTACT PERSON PHONE <br /> G LOCAL AGENCY AGENCY NAME _ ,^T Ey) j,J f3 1 <br /> Z. <br /> Z USt4l C 3 TWI PHONE <br /> w w <br /> REGIONALBOARr <br /> E QUANTITY LOST(GALLONS) <br /> -}/�^/ (c�.� (. ��j j/.�} .}1.NA�MEyn, . . M 1 _ <br /> <w ('I 1 �v .' F-- �4/ / 1 / C1'" +'�"�— /VY UNKNOWN C> <br /> m (a) ❑ UNKNOWN <br /> N� <br /> I- DATE DISCOVERED HOW DISCOVERED Li INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDI ;ONS (� <br /> z0❑ TANK TEST ❑ TANK REMOVAL x OTHER A <br /> U uI ✓u o o Y • METHOD USED TO STOP GE(CHECK ALL THAT PLYfl <br /> < DATE DISCHARGE BEGAN <br /> a UNKNOWN ❑REMOVE CONTENTS yv CLOSE TANK&REMOVE ❑REPAIR PIPING t <br /> w u o o Y Y ❑REPAIR TANK /❑�CLOSE TANK&FILL IN PLACE []CHANGE PROCEDURE �f, <br /> HAS DISCHARGE BEEN STOPPED 7 '\1 <br /> o YES ❑ NO IF YES.DATE U MI u Y Y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSES) <br /> UW. ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> ❑ TANKLEAK UNKNOWN OTHER <br /> �N o <br /> < UNKNOWN <br /> mLT ❑ PIPINGLEAK ❑ OTHER ❑ CORROSION <br /> ww CHECK ONE ONLY <br /> u ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER E] DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY ❑ POLLUTION CHARACTERIZATION <br /> iH � NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SueMITTED <br /> w ❑ POST CLEANUP MONRORING IN PROGRESS <br /> ¢r ❑ LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ <br /> w`^ <br /> r-1REMEDIATIONCLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> REMEDIATION PLAN ❑ <br /> CHECK APPROPRIATE ACTION(S) ❑ E%CAVATE8015POSE(ED) ❑ <br /> REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> <Z Ist%<+iw oeTuel <br /> E%CAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ❑ CAP SITE(CO) ❑ <br /> v ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) <br /> ❑ TREATMENTATHOOKUP(HU) VENT SOIL(VS) <br /> a VACUUM-EXTRACT(VE) ❑ OTHER(OT) <br /> sot-z, C2 C1 AR.C10Y1 d� 0. 1 <br /> `-7 JA S .�J LI CI P xsc ss lv9m <br /> 1 Y " <br />