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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 /> ❑ <br /> YES UCI NO REPORT BEEN FILED i ❑ YES NO I HEREBY CEHTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> f-�' DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE CASE III <br /> o SMI 0 9 2y &cKED 7.y&r°r%.� - Zvl a/ <br /> 11 DATE <br /> NAME OFINDIVIDUAL <br /> -FILING REPORT PHONE SIGNA <br /> REPRESENTING OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> S ❑ LOCAL AGENCY ❑ OTHER Ck?vYP,^- U4-S1A ��Odk s Co <br /> R! ADDRESS <br /> Z�Ic� C0.N�ivw �Gzvtior\� 5a. ,- "Rt�Wnnv� CA g45193 <br /> STET CITY STATE ZIP <br /> w NA /�\\ CONTACT PE{P—SON -�j <br /> C1ME�n£\/fov� 1ASJT ❑ UNKNOWN G\Vl-` 1�-O E�Y,�j ( E (a"V�) <br /> hg ADDRESS _1 <br /> crtr STA <br /> EEr IP <br /> FACILITY NAME(IF APPLICABLE) sTROPERATOR HONE <br /> $ [A iF fav 5"l"6t:L'AA- # I- 5J4 q 0 `g a b Jov'�5 (1611�(lo3 '533 <br /> a ADDRESS <br /> s Iz E. Na.d�L� �WaY SFo�k�o SatiJoawv. 95205 <br /> cm <br /> CROSS STREE/TAy 1} <br /> / 111 tJ r 1 <br /> O LOCAL AGENCY AGENCY NAME CONTACT PER"tffaN <br /> €w SOL, JO Wt.o' co . � u � 4 � (Zo9)�{b8 3Q50 <br /> w REGX)NAL BOA D ^ N .s <br /> a� CatiF�a� Vall> AUG 1 8 1992 PHONE <br /> � (q16) <br /> NAME FNVyLIRONMI-pENTAL FTEM QUANTITY LOST(GALLONS) <br /> aj SlA {fMAE_ uh(F� �0.5o(•hf- f' tT'wllyUI�RVI�',i~� UNKNOWN <br /> m <br /> N <br /> ❑ UNKNOWN <br /> i DATE DISCOVERED HOW <br /> jDISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> OW <br /> D Z Y ,ICI TANK TEST F-1TANKREMOVAL ❑ OTHER <br /> i DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UP M D v y UNKNOWN ❑REMOVE CONTENTS E:]CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED 7 I1'lf ❑REPAIR TANK ❑�1 CLOSE TANK&FILL IN PLACE/If��II CHANGE PROCEWRE <br /> a % YES ❑ NO IF YES.DATE V I 'q 9 y Z y ❑REPLACE TANK I]C I OTHER G�^^- �lp$>< <br /> SOURCE OF DISCHARGE CAUSE(S) c� <br /> c a �' TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> HO ❑ PIPING LEAK ❑ OTHER E] CORROSION UNKNOWN ❑ OTHER <br /> wa CHECKONEONLY <br /> XUNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w� ❑ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(% ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCEOBIO DEGRADATION(En <br /> IP�>•cRrwo[Tiael <br /> 4 53 0 ❑ CAP SITE(CD) EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Zti ❑ CONTAINMENT BARRIER(CS) ❑ NO ACTION REQUIRED INA) ❑ TREATMENT AT HOOKUP(HL1) ❑ VENTSOIL(VS <br /> ❑ VACUUM EXTRACT(VE) B( OTHER(OT) G,Eckn InV GY.�O raeorofs r 'CCA- <br /> Ta.Y.k �qa�lso( 1 �k� amass f s�. -Car\k f✓ F'}iE'01/ +I;L� OF se'ro'cE <br /> 8 0.Y.d ihVfM�ory r�CorC�(S VG -1 �/�L.a leak" .•.I /•I I,sc la Lasa <br />