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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 /> REPORT BEEN FILED 7 <br /> ❑ YES ® NO ❑ VES No 1 HEREBY CERTiFYTHAT.I,HAVE DISTRIBUTEDTHIS INFORMATION ACCORDING TOiHE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE GASEN <br /> M I 3 Y SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> w REPRESENTING ® OVINERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> S ❑ LOCAL AGENCY ❑ OTHER <br /> ¢ ADDRESS <br /> aa►, � L a�FA�? E. : A\A- NE.�PoKr 6EAcr� C�k �ILr <br /> J NAME CONTACT PERSON PHONE p <br /> i Rq �n�. ❑ UNKNOWN I'n '? (.J�NN1 t/�-��..t7 ((01x7) <br /> Hy ADDRESS <br /> I G`50 s, GttuRcrt -vr. 'b o Te 301 rnL)Ps sPJLDR o tnl 31►30 <br /> STREET CT' STATE vp <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> 9-q vs, tiC, lolR��?►7�fL`TQucK Iz*s,n*( (209) q�3. 3�3 <br /> ADDRESS C <br /> s 3c�33 �xac GRc 4 ►J6 Srr�c k~v� )A� �cDAQu)J q�2►5 <br /> ly STREU CRY (AUNTY ZIP <br /> V-; CROSS STREET - <br /> ,)TACaECURGN RvA-0 <br /> i LOCALAGENCY n AGENCY NAME CONTACT PERSON PHONE <br /> iw Sc A,3 �oAgUtnl WJNtQ �aJVr I►L�{ l�1NA /�cPihhlE (ICA) 4(o$- A4bCb <br /> w <br /> w w REGIONAL BOARD PHONE <br /> 91 t�.i-_t•1T(Z Az YAL-E-J (91(0 )255- 3w a <br /> w p) NAME QUANTITY LOST(GALLONS) <br /> w O <br /> j ►� UNKNOWN <br /> N <br /> ❑ UNKNOWN <br /> r DATE DISCOVERED �j HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> OMI 9-1 1 -1 $DI OYJ v ❑ TANK TEST ❑ TANK REMOVAL fs],OTHIIf4G7 �"D�SQ�NSLSZ1�u�vJVM- <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w <br /> Ml 01 01 yl r <br /> ❑ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK 8 REMOVE ❑REPAIR PIPING <br /> sHAS DISCHARGE BEEN STOPPED 71 ii ❑REPAIR TANK ❑CLOSE TTANK,&FILLL IN PLACE ❑CHANGE PROCEDURE <br /> o YES E:] NO IF YES,DATE C)u 9,j Di L bv 3v ❑REPLACE TANK gOTHERREPI.l4c,E FISP. A,iO I�,PI�Er <br /> SOURCE OF DISCHARGE CAUSES) <br /> �`j ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> hO F-1 PIPING LEAK TS-OTHER--D%-) q ❑ CORROSION UNKNOWN ❑ OTHER <br /> ywn CHECK ONE ONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> i ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ¢� <br /> cr ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> G y <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) '�I CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) TSL'EXCAVATE B DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> IaEE S.CR RlP0ETN81 <br /> pE2 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY IRS) <br /> ufU ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED INA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENTSOIL(VS) <br /> Qa <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> ARPRolimA--ML? 30 -r61.,s of 5U1L CuIaYArlir )b DVe'aEL- jA'5EXr-AvA'M0 FPao b&-*" <br /> z. '3o." -4,wL 6E 'T vvr4sl?4Ak' > -co Ar z*I�GLmA-� <br /> HSC M(MO) <br />