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%owl, ! — <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGE SERVICES -POR LOCAL AGENCY USE ONLY . <br /> REPORT BEEN FILED 7 1 HEREBY CETEIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ VES NO VES NO <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE CASE A /J /j 3. / <br /> DM 3 r SGKED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE 0 SIGNATURE <br /> oz_— (4209) �60 <br /> w REPRE NO O OWNER/OPEMTOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME _ / / <br /> S LOCAL AGENCY ❑ OTHER n V Ou V/n w p l L 460 1 C <br /> ADORESy5' Al. Sun J as uin <br /> Sloipr"4fv/. G9- yVo <br /> STREET ` Cm STATE ZIP <br /> j NAME / �S/ .� CONTACTPERSON PHONE <br /> i¢ <br /> ow. S SI ❑ UNKNOWN Joe O `lea. (2x91 "9,-a/3 <br /> Oa ay ADDRESS <br /> ivy Acauc� Sf• /p/�un C4 9S�GG <br /> STREET Cm STATE mp <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> le <br /> a ADDRESS qr r <br /> 3 oy Aca cea A?c Cj a„ Toa�u.n N <br /> w STREET m CWMr 21P <br /> y CROSS STREET <br /> �cJ q 9 <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> u lac <br /> w <br /> wI REGIONAL BOARD PHONE <br /> n a ( 1 <br /> 3 I <br /> y p) <br /> NAME QUANTITY LOST(GALLONS) <br /> rf(./1000n SO/lam ee el E::] UNKNOWN <br /> m ❑ UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED ENTTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> r ❑ TANK TE T#NK REMOVAL J ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> Ml d 01 yl <br /> >O HAS DISCHARGE BEEN STOPPED T ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> D ❑ YES ❑ NO IF YES,DATEM M o r v ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> o ❑ TANK LEAK E24KNOWN ❑ OVERFILL O RUPTUREIFAILURE O SPILL <br /> rn0 ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> 11 <br /> w w CHECKO ONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY (� <br /> i� ❑ NOACTK)NTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> =y ❑ BEING PL�CONFIRMED � PRELIMINARY <br /> A EE (CLEANUP <br /> IE <br /> CLO CLOSED COMPLETED OR UNNECESSARY) ❑ CLLANUP UNMONITORING IN PROGRESS <br /> DE WAY <br /> EMEDAT ' <br /> U <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATK)N(IT) r <br /> Is46�CI(RA o[iM81 <br /> So 9 ❑ CAP SITE(CD) E:] EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)E:] REPLACE SUPPLY(RS) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) O TREATMENT AT HOOKUP(HU) O VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(On <br /> i FUp�/if/T s./r assess- W% bP &e ces sa-c -/v cle Ae./^ i n t¢fiuo dAc.el <br /> i �C{?nf oI co /0 W.-4-/ln, as ree"fowpC dy � loci ie�Jcu/wfia� <br /> $ �(, .&c O Hsc aslasol <br />