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�4fv�-, qq qqus 3 <br /> UNDERGROUND STORAGE TANK UNAIJT&ZEb RELEASE(LEAK)I OONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGE MUSE ONLY : <br /> REPORT BEEN FILED T . <br /> ❑ YES NO <br /> YES NO 1 HEREBY CERTIF.YTHAT.t-HAVE DISTRE.=T'H14INFORMATION ACCORDING TO THE ' <br /> % r -DNSTREUTION SHOWN CIN THE INSTRUCTION SHEET-ON THE SACK PAGE OF THIS FORM <br /> REPORT <br /> �DATE <br /> CASE s O� c <br /> s VI Oa { •' 1 <br /> r D �U 'SICNED OTE <br /> NAME OF INDIVDUALFILING REPORT PHONE SNGNATUAE <br /> co <br /> Lu REPRESENTING CEMOPE T66 REGIONAL BOARD COMPANY R AGENCY NAME <br /> 12 ❑ LOCAL AGENCY OTHE �}, ,tea , C6 <br /> uj <br /> cc ADDRESS <br /> c) Orrc, STATE l.Ol rP3 7 <br /> to NAME CONTACT PERSON PHONE <br /> coJ <br /> i¢C � �i C9 Co. 173UNKNOWN , {7 t, ) G M-A cq <br /> a ADDRESS p <br /> 4u <br /> cc I{(y� �1 /9 <br /> V STREET Lo/y` s s � CRY L� STATE. CA p �6 <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> U ADDRESS <br /> o <br /> w 13 o Sri. ST. W L\ o,ry �G C1L-TC�1ry rowrrY lwi,, P <br /> H CROSS STREET <br /> %N G-r&-A <br /> p LOCAL AGENCY AGENCY NAME CONTACT PERSON .. PHONE <br /> U)Lu -Z�on -Zogsl CLE 2a9) 1461 . b <br /> L2 <br /> REAIeNY SHARD PHONE <br /> � -�kc� ty Co . e�,J,, COT 1 \ �aUG 1s� tvv�s (UM 4ko%..3gy6 <br /> H (i) NAME QUANTITY LOST(GALLO" <br /> r w O <br /> ! Z> Q 6-4[)`th� UNKNOWN <br /> �J <br /> co <br /> UNKNOWN <br /> DATE DISCOVERED HOW O'S <br /> C� C��} COVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> �uI � 2 0 �r 1 Y El TEST 1:1TANK REMOVAL OTHER <br /> 4 <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPL <br /> cr Lu <br /> u o Nr UNKNOWN E]REMOVE CONTENTS CLOSE TANK 8 REMOVE ❑REPAIR PIPING (� <br /> HAS DISCHARGE BEEN STOPPED 1 / ❑REPAIR TANK CLOSE TANK A FILL IN PLACE CHANGE PROCEDURE <br /> YES ❑ NO IF YES.DATE u N` �~ Y Y ❑REPLACE TANK OTHER K lV I YV G <br /> t5 <br /> SOURCE OF DISCHARGE CAUSE(S)uJ <br /> ' <br /> ¢In ❑ TANK LEAK UNKNOWN Q OVERFILL RUPTURFIFAILURE SPILL <br /> ❑ PIPING LEAK ❑ OTHER ❑ CORROSION MUNKNOWN O OTHER r' <br /> t in a CHECK ONE ONLY �h <br /> L) UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wcn <br /> ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> ¢ <br /> y LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> cO ❑ REMEDIATION PLAN ❑ CASE CLOSED{CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK A <br /> E RI APPROPRIATACTION(S) ❑ EXCAVATE b DISPOSE(ED) <br /> 4>P OTE ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(TI) <br /> J <br /> wQ❑ CAP SITE(CD} ❑ EXCAVATF-&TREAT(ET) ❑ PUMP 3 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w ❑ CONTAINMENT BARRIER{CB} NO ACTION REOUtREp{NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VEy OTHER(OT) �G � �M� E1� <br /> QlYJo(�G�,. Qx1���5 � � }, � o.�.r] rn a q -t�„c,.k- -�•."� { y <br /> TPN n ►1r. hp � +z.,��' rwro)v- N IJ -& S.Ib wil . N <br /> vYA.n JA tc,, ,J�Q.e1.. 01 CD tv v. r'NAAKQlak I o Saar v <br /> - - 1490 os Idoq <br />