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9c <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> VES NO <br /> (rte/ REPORT BEEN FILED 7 O YES Q NO 1HEREBYCERTIFYTHATI HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATECASES <br /> SIGNED 4' DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> �a/ O (� ) yloY3yy J <br /> w REPRESE REGIONAL SOARD COMPANY OR AGENCY NAME <br /> Q OWNER�OPERATOR Q / <br /> S LOCAL AGENCY D OTHER �U n TQ' C//� �GC 9• Ilea /A S f,-v!C`s <br /> ¢ ADDRESS <br /> S N, Scr/7 Tvu �cc%n S/oc��i/» C <br /> srnEEr cm UAW <br /> ar <br /> w NAME CONTACT PERSON PHONE <br /> ` <br /> x <br /> /:W/7 L S //1 Oa'O UNKNOWN �{'�� .J /!7 <br /> i ADDRESS <br /> /o// N �ro�c/%� S�vrk �vn 93 <br /> &rREEr cm srATEZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> S i<i L kLf-:5G 10 <br /> a ADDflES <br /> 8 /0// /v /Sr ocr��c'G�c S G. a�7 j T 1/SZ6L <br /> W STREET CRY W NTY mp <br /> y CROSS STREET <br /> /4�finvnf f� <br /> p LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> W <br /> w� <br /> REGIONAL BOARD PHONE <br /> as <br /> f <br /> w (11 NAME QUANTITY LOST(GALLONS) <br /> U2w w /e't NKNOWN <br /> 6 J <br /> �z m <br /> m UNKNOWN Q�A` <br /> i DATE DISCOVERED HOW DISCOVERED F-1 POENTORY CONTROL SUBSURFACE MONITORING Q NUISANCE CONDITIONS V <br /> 2 M / u Y TANK TEST TANK REMOVAL O OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE CK ALL THAT APPLY) <br /> ¢ M D Y Y �-I UNKNOWN ❑REMOVE CONTENTS LOSE TANI REMOVE O REPAIR PIPING (� <br /> HAS DISCHARGE BEEN STOPPED? REPAIR TANK O CLOSE TANK 8 FILL IN PLACE ❑CHANGE PROCEDURE <br /> YES ❑ NO IF YES,DATE u M o r Y ❑REPLACE TANK O OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> TANK LEAK ER <br /> UNKNOWN OVERFILL RUPTURHFAILURE Q SPILL <br /> Q PIPING LEAK Q OTHER D CORROSION Q UNKNOWN Q OTHER <br /> yw6 CHECK ONE ONLY <br /> O F-1 UNDETERMINED ❑ SOILONLY Ej GROUNDWATER O DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> riwZ NOACTIONTAKEN Q PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED Q POLLUTION CHARACTERIZATION <br /> m LEAK BEING CONFIRMED 0 PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> Q ❑ REMEDIATION PLAN F-1 CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) Q ENHANCEDBIO DEGRADATION(IT) <br /> I�ewxsanoaT.aal <br /> 4 CAP SITE(CD) EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT)0 REPLACE SUPPLY(RS) <br /> ~ F-1 CONTAINMENT BARRIER(CB) NO ACTION REQUIRED INA) TREATMENT AT HOOKUP(HUI O VENTSOILNS) <br /> wQ <br /> VACUUM EXTRACT NEI Q OTHER(OT) <br /> sa. /q/r icsu/fs Ank frrwvc�0 t c�� L7o� •�<•+tv <�- <br /> ywr�i� ssfr ajsess<.La/�` w`•!i 6,e necers�.y �{o c,/r <br /> $ <br /> eXn Con�.P�i ��'" Gtt Vu/Ary �Li �ocfec� (il�{ay GCc}E <br /> J O Nx snln <br />