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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES `FOR LOCAL'AGENCY USE ONLY <br /> ❑ YES p)D <br /> REPORT BEEN FILED? Q VES E NO I HEREBY CERTIFYTHAT I,HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE CASE• <br /> r SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> / O e__ ('t?) yw-gY <br /> w REPRES G COMPANY OR AGENCY NAME <br /> F I 1 OWNERIOPERATOR Q REGIONAL BOARD <br /> ¢ LDCAL AGENCY 0 OTHER <br /> S <br /> ADDRESS <br /> �l YS N • San Iva�u r%T .�� �ic,�-gym, C� 9S'20 / <br /> >RR�tT cm STATE ZIP <br /> J NAMEqq CONTACT PERSON PHONE Ley <br /> UNKNOWN <br /> � Qs' (Z� Y��o �7[� <br /> a g ADDRESS �� <br /> z/36 14..)A Scof-/s Ake �Sic�fv+-� G4 9's10 <br /> BiREE! Gm STATE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> cy C/,! <br /> o /9GL u (�11 L Wo <br /> a ADDRESS� c !3C7D /' i-orp�iR .Sf_ 5;4tx,6{v�-t /Q dCo <br /> F srREET cm coin S ( P <br /> m CROSS STREET <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z <br /> Ll <br /> REGIONAL BOARD PHONE ) <br /> a <br /> m LII NAME QUANTITY LOST(GALLONS) <br /> a a <br /> UNKNOWN <br /> Z (2 <br /> H e a Q UNKNOWN %(� <br /> •-. DATE DISCOVERED HOW DISCOVERED �•.1 <br /> w ❑ 1 TORY CONTROL SUBSURFACE MONITORING 0 NUISANCE CONDITIONS <br /> 14 oj <br /> A14YI 0 TANKTEST TANK REMOVAL ❑ OTHER <br /> METHOD USED TO STOP <br /> E(C ALL THAT <br /> m DATE DISCHARGE BEGAN O UNKNOWN REMOVE CONTENTS ISCHARGOSE TANKER MOVE APPLY) <br /> REPAIR PIPING <br /> M Y IIY Y <br /> g HAS DISC GE BEEN STOPPED 7 E:]REPAIR TANK Q CLOSE TANK&FILL IN PLACE a CHANGE PROCEDURE pG <br /> YES O NO IF YES,DATE O REPLACE TANK O OTHER <br /> M V Y <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> TANK LEAK ❑ UNKNOWN ❑ OVERFILL RUPTUREIFAILURE ED SPILL <br /> w O F-1 PIPING OTHER CORROSION 0 UNKNOWN O OTHER <br /> h w CHECK ONLY <br /> O UNDETERMINED 0 SOIL ONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> wZ NO ACTON TAKEN Q PRELIMINARY SITE ASSESSMENT WO RKPLAN SU BM ITTED E::] POLLUTION CHARACTERIZATION <br /> jy LEAK BEING CONFIRMED 0 PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> O Q REMEDIATION PLAN F--j CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) 0 EXCAVATE B DISPOSE(ED) O REMOVE FREE PRODUCT(FP) O ENHANCED BIODEGRADATION(IT) <br /> IBff AY Pn Pt.� <br /> Q rI CAP SITE(CD) EXCAVATE 8 TREAT(ET) PUMP&TREAT GROUNDWATER(GT)O REPLACE SUPPLY(RS) <br /> < CONTAINMENT BARRIER(CB) O NO ACTION REQUIRED(NA) F-1 TREATMENT AT HOOKUP(HU) O VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) OTHER(OT) ! <br /> lr-"rll S!Ir w.// �P neeCcsCicS. �a c�ef'G.r>r..:..r <br /> hft-fi.(i�t a^00`e r yes, <br /> AW 0(11" <br />