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• uta <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)!CONTAMINATION SITE REPORT <br /> EMERG CY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> REPORT BEEN FILED a FOR LOCAL AGENCY USE ONLY <br /> 0 YE 4� NO Q YES ❑ NO 1 HEREBY'CERT3FYTHAT A11HAVE DISTAIBUTED THIS INFORMATION ACCORDING TOTHE <br /> DISTRIBUTK)N SHOWN ON.THE.WSTRUCTION SHEET ON THE BACK,P.AGE OF:THIS FORM <br /> REPORT DATE p� CASES <br /> t.%i O l v ",SIGNER DATE,, <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIG <br /> cn r'I '1ri +r.�`�L <br /> >- (W9) <br /> '}68 34ya <br /> w REPRESENTING Q OWNERIOPERATOR 0 REGIONAL 80ARD COMPANY OR AGENCY NAME <br /> Q <br /> Lu � LOCALAGENCY ❑ OTHER <br /> ¢ ADDRESS <br /> 30 44 r, w � Ary Sc-�r 9sloz <br /> STREET CITY STATE ZIP <br /> w NAME CONTACIPERSONPHONE <br /> J / <br /> Z ( UNKNOWN M I kC Z21T'oN {ZO ti d <br /> aa ADDRESS <br /> LiciIto <br /> acs � � cG-�.��~�. 3 <br /> STREET CRY STATE Zlp <br /> FACILITY NAME(iF APPLICABLE) OPERATOR PHONE <br /> U DDDR S 1Aj�"M©P-C ^-,J mapav 11Q 45-3(� <br /> a z 10 N4� Z4 S <br /> w STgEET CRY COUNTY 21P <br /> CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z� <br /> ~w <br /> W U <br /> w REGIONAL BOARD PHONE <br /> NAME QUANTITY LOST(GALLONS) <br /> LU <br /> Zw <br /> J UNKNOWN <br /> a <br /> ch <br /> y ❑ UNKNOWN <br /> i DATE DISCOVERED q HOW DISCOVERED 0 INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> d u1 M 0 0 1 r� r ❑ TANKLu <br /> TANKREMOVALIQ OTHER <br /> c <br /> m DATE DSSCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> w M M 0 D Y Y <br /> }D HAS DISCHARGE BEEN STOPPED 7 EDREPAIR TANK ❑CLOSE TANK&RLL IN PLACE E]CHANGE PROCEDURE <br /> w ❑ YES ❑ NO IF YES,DATE M o r r Q REIPLACE TANK Q OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> ❑ TANK LEAK NTH] UNKNOWN *lm 11 11RUPTURE/FAILURE SPILL <br /> v)L) 0 PIPING LEAK ❑ OTHER Q CORROSION � UNKNOWN ❑ OTHER <br /> +y w CHECK ONE ONLY <br /> w. %�n UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER •(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTEO) <br /> CHECK ONE ONLY <br /> zQ NO ACTION TAKEN a PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> 1r1r;5 ❑ LEAK BEING CONFIRMED a PRELIMINARYSITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U Q REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OA UNNECESSARY) 0 CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> L]O (SEE SACK PM oETALS) <br /> Q CAP SITE(CO) Q EXCAVATE&TREAT(ET) Q PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> tu m¢ ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) I❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> Lu <br /> s ❑ <br /> VACUUM EXTRACT(VE) Q OTHER(OT) <br /> z <br /> g <br /> �o <br /> O <br /> MSL 0.5(SBC) <br />