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...� >lomw 9b--cc 7q <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY'. <br /> FD YES REPORT BEEN FILED?T ❑ ❑ I HEREBY CERTIFY <br /> THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE; <br /> vEs REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT.TO 8EC7K}N 25180.7 OF, <br /> REPogroaTE (�/�/\' casEa 1HEH ANtl YCODE <br /> 6M SM yj <br /> I D <br /> NAME OF INDIVIDUAL FILING RE RT PHONE SIGNATURE <br /> Le fi h` c4- E�v`t)It 6�-3Y3 <br /> cREPRESE G <br /> OWNER�OPERATOR O REGIONALBOARD CO1M PONY OR AGENCY NAME l <br /> u LOCAL AGENCY O OTHER Q1J C PHS 9, 14, UY �/' <br /> ADDRESS —1 (/ <br /> �. 6 , &x a 009 346 CA 1`�aa7 <br /> DRY <br /> EET <br /> WATEZIP <br /> m NAME +I� CONTACTPERSSOO'N q PHONE ('y� <br /> S �D� /J ❑ UNKNOWNgJA�D <br /> n ADDRESS � 6 <br /> i �soa N. CLz roq4^ <br /> FACILITYNAME(IFAPPLICABLE) � �� �� / p <br /> OPERATOR PHONE <br /> U� Sf, o se 0S sa mc_ �919y3-A000 <br /> ADDRESS <br /> O 0 <br /> 1800 N. Cum ct— S'�oC�, S:`� e 5sa0v <br /> CWKY <br /> m CROSS STREET P <br /> m LOCAL AGENCY AGENCY NAME CONT CTP:,, p(p <br /> NE <br /> SQ,rL�er� S-- n 00 X68 3 ab <br /> �a REGIONAL BOARD PHONE <br /> C O C c <br /> 0 L,1 NAME QUANTITY LOST(GALLONS) <br /> z� <br /> AO UNKNOWN <br /> (2) <br /> Ij UNKNOWN <br /> z DATE DISCOVERED HOWDISCOVERED Q INVENTORY CONTROL O SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> Y TANK TEST Q TAN(REMOVAL f OTHER <br /> 047E DISCHARGE BEGANMETRO PBED TO STOP DISCHARGE(CHECK ALL THAT LV) <br /> M M D D <br /> UNKNOWN REMOVECONTENTS O REPLACETANK LOSE TANK ' <br /> >Q <br /> ASC GE BEEN STOPPED?Y Y�\ f REPAIRTANK REPAIRPIPWG E] CHANGEPROCEDURE <br /> 205 VES Q NO FYES,DATE VM ,,;�u ()DI ;11D 9Y V v OTHER <br /> Q SO,,,,,,U��UR���R,C,,,E//////QQQQQQFFFFFF DISCHARGE CAUSES) <br /> �K LEAK O UNKNOWN O OVERFILL O RUPTURE/FAILURE O SPILL <br /> PIPING LEAK O OTHER CORROSION KNOWN OTHER <br /> w w <br /> CHECK <br /> UNDETERMINED SOIL ONLY GROUNDWATER O DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) �(\ <br /> CHECKON NLY 4 <br /> cZ NO ACTION TAKEN O PRELIM(NARY SITE ASSESSMENT WORKPLAN SUBM IT TED O POLLUTION CHARACTERIZATION <br /> tiN LEAK BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> Q <br /> REMEDIATION PLAN O CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) O REMOVE FREE PRODUCT(FP) O ENHANCED Bp DEGRADATION(IT) <br /> ,aEe�cRrmoeT,�p <br /> W 04 a CAPSITE(CD) O EXCAVATE&TREAT(ET) O fK)MP&TREAT GROUNDWATER(GT) Q REPLACE SUPPLY IRS) <br /> ¢� O CONTAINMENT BARRIER(CB) O NO ACTION REQUIRED INA) TREATMENT AT HOOKUP(HU) O VENTSOIL(VS) <br /> O VACUUM EXTRACT(VE) O OTHER(OT) <br /> Q <br />