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�► o �o <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? <br /> YES NO VE <br /> I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TOTHE <br /> ❑ ❑ SNO <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> fREPORT DATE CASE <br /> V N R l U lJY SIGNED DATE. <br /> N E OF IN VIDUAL FILING REPO PHONE SIGN RE <br /> LIa N� (? () �� qgZJQ? I <br /> O REPRESENTING ANY OR AGENCY NAME <br /> w ❑ OWNERIOPERATOR ❑ REGIONAL BOARD <br /> S LOCAL AGENCY ❑ OTHER - Q �y- 141 <br /> �) <br /> ADDRESS <br /> Ljotoer7- Ave_ c ` gs�ZI- <br /> srRel¢r elry srAre ZIP <br /> w NAME CONTACT PERSON 1 Q o PHONE <br /> m ❑ UNKNOWN <br /> z <br /> y a AoQnESS <br /> �Q <br /> w <br /> srReer cm srATe ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> �AN, <br /> ( <br /> o �ADDRESSo Lj, �3+ L _ IL1) <br /> �Szlv <br /> Z{O <br /> w <br /> y CROSS STREET <br /> CA, <br /> O LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> 2y OzW ( ) <br /> w� <br /> REGIONAL BOARD PHONE <br /> H (�) NAME QUANTITY LOST(GALLONS) <br /> zw \T ❑ UNKNOWN J� <br /> m (2) <br /> w \SIL. ❑ UNKNOWN T� <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑AA ..NUISANCE CONDITIONSyj <br /> Ir\ <br /> 1D ❑ TANK TEST E] TANK REMOVAL OTHER IIA-, ( (N3 <br /> NI MI D Y <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> oml d DI I <br /> HAS DISCHARGE BEEN STOPPED 7 Y ❑REPAIR TANK ❑CLOSE TANK a FILL IN PLACE ❑CHANGE PROCEDURE <br /> O YES ❑ NO IFYES.DATEM I D r Y ❑REPLACE TANK E::]OTHER <br /> SOURCE OF DISCHARGE M CAUSE(S) <br /> a ❑ TANK LEAK / I UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> 00 ❑ PIPING LEAK --CC❑--" OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> ww CHECK ONE ONLY <br /> u DETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> �y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O REMEDIATIONPLAN ❑ 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 /> I�encn wn or•T,ue1 <br /> a z ❑ CAP SITE(CD) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP A TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w0 <br /> w< F7CONTAINMENT BARRIER(CB) ElNO ACTION REQUIRED(NA) ❑ TP.EATMENT AT HOOKUP(HU) E_ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) <br /> ❑ OTHER(OT) <br /> zz <br /> w <br /> 0 <br /> O <br /> Q <br /> MSC 0(MO) <br />