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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES II FOR LOCAL AGENCY.USE ONLYd. <br /> ❑ YES �� REPORT BEEN FILED? YES �NO I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> flEP,pR� THIS WFQflMAT10N TO LOCAL OFFICIALS PURSUANT TO SECTION 251807 OF. <br /> REPORTT�DATE'\ CASE# THE' f <br /> 0 u Lu U u o 1 v v SIGNED—.: y L ( J DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGN <br /> > �,Pl� ✓ �� (moi)48-3oc( <br /> m <br /> REPRESENTING ❑ OWNEIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> n dLOCALAGENCV ❑ OTHER s.�NviNco J)ulf3t-1C_NE.A��r { ievr�5 <br /> ¢ <br /> ADDRESS <br /> yJN 5o9m�iN SbKI 95LoZ <br /> SWIMCrtY STATE nP <br /> w NAME - r. /, CONTAACTIPEERSOON,//�r�- .PHONE / [� <br /> v4l_Yf l f-Af THE ❑ UNKNOWN <br /> S n ADDRESS <br /> D. �O S`67o ST��K7a� c.0. gC�Zo S <br /> &TREEr crtY HTATE n <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> 494 <br /> ADDRESS <br /> !O.e/D /v' U �D�I 57o� N SRnI J0AkP0'N 057-07 <br /> CITY ccuxryAP <br /> �+ CROSS STREET <br /> i LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> SAN�OA(J>rNC0 �VBG� //FAdTFSF�VK65 �iQ/L �EY�N/q (7" 616$-34-39 <br /> w�` REGIONAL BOARD PHONE <br /> m (1) NAME QUANTITY LOST(GALLONS) <br /> 610 Pi6vo4&JN4 0YD/90c49PoAS U^- KN/DWN <br /> m (2) <br /> N ❑ UNKNOWN <br /> i <br /> DATE DISCOVERED / HDW DISCOVERED ❑ INVENTORY CONTROL /SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> vu 2u OD V D �Y I Y ❑ TANKTEST ❑ TANKREMOVAL BOTHER /1'GZ7 R�YrO4,, <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY)) <br /> M M o o v Y UNIKNOWN ❑ REMOVECONTENTS ❑ REPLACETANK CLOSE TANK <br /> Q HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIRTANK ❑ REPAIRPIPWG ❑ CHANGE PROCEDURE <br /> S ❑ YES ❑ NO IFYES.DATE M .1 o DI v ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) ' <br /> ¢a O LWKLEAK UNKNOWN ❑ OVERFILL O RUPTURE/FAILURE ❑ SPILL <br /> O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION 0 UNKNOWN ❑ OTHER <br /> ww CHECKONEONLV <br /> ❑ UNDETERMINED ZSOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w� LJ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT VIORKPUN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> �y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUPUNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BK)DEGRADATION(IT) <br /> IfftewcragoErwq <br /> F3 ❑ CAPSITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> �� ❑ CONTAINMENT BARRIER(CEI) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENTAT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> F-1 VACUUM EXTRACT(VE) dOTHER(01`) "W OtV6LI <br /> IAkAI( fN/,E T'4I4x RE'c*OL l_ /RFO ftl:'D Ort l� <br /> Ay Z3, )cl?6 foil F IA's-ME PQF-S FlJG"E� of CoNT,dFt I NA-T9s. FiDR7w-+se? S l�B A-ss Z5Sc.u6N'T K1It-L <br /> r3s REo�rrEE.o ry v��ti'urN� n+�N SeE d^/p xrENroFe-oA17rA-Q'1'1 p- -1&"J 45 XQUIRan <br /> H �y THE APJ��PRl,Q7-E RKiI>/-.d�'o.�YA6ENGY. <br /> K&C 06L11AYi <br />