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- u77 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGE ERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 <br /> ❑ YES NO YES O NO 1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> REPORTDATE DISTRIBUTION SHOWN ON THE INSTRUCTION SHEETON THE RACK PAGE OFTHIS FORM <br /> {Y G CASE• <br /> O 4 / SIGNED <br /> NAME OF INDIVgUAL FILING REPORT 'L' DATE <br /> PHONE SIGNATURE <br /> m r0 / Y6�3vYD <br /> w REPRESE G ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COM PANYORAOENCYNAME <br /> LO <br /> S CALAGENCY ❑ OTHER nv. u,6 �[C /7c4 ��h +y✓([� <br /> 2 ADDRESS <br /> 41 Soren SY, 5a0 <br /> CRY S A E <br /> wm NAME n. <br /> CONTACT PERSON PHONE <br /> ADDRESS ❑ UNKNOWN 1 <br /> STREET CRY STATE ap <br /> FACILITY NAME(IF APPIZBLE) OPERATOR PHONE <br /> SR 1404 Sv m e-s (dol) Lf(.3-S33) <br /> O ADDRESS <br /> Ao v < , .�1. G✓ <br /> w $TREE! CRY COIIMfY P <br /> H CROSS STREET <br /> O LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> z N <br /> ~ ( ) <br /> W <br /> W w REGIONAL BOARD PHONE <br /> �O <br /> as <br /> m I11 NAME QUANTITY LOST(GALLONS) <br /> w Q ti <br /> <� KNOWN <br /> r <br /> m� m <br /> w ❑ UNKNOWN <br /> i DATE DISCOVERED HOW D RED O INVENTORY CONTROL ❑ SUBSURFACE MONITORING Q NUISANCE CONDITIONS <br /> u u -3 -12 Y TANK TEST ❑ TANK REMOVAL .O OTHER <br /> m DATE DISCHARGE BEGAN METHOD D TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w u - D 0 Y v UNKNOWN REMOVE CONTENTS ❑CLOSE TANK 6 REMOVE ❑REPAIR PIPING <br /> 8 HAS DIS RGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o YES ❑ NO IF YES,DATE .1 MI DI dy y ❑REPLACE TANK ❑OTHER V <br /> SOURCE OF DISCHARGE CAUSES) <br /> a ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> HQ ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> w w CHECK ONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wZ ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> jy ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION($) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BID DEGRADATION(IT) <br /> PEE�RA oer,un <br /> A O ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP 8 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w� <br /> W< ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> W <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> y rz[%rf / T. Fcu�lCc inver{e���[� cis A, L. is kuLe c/-+-o. <br /> z 1 <br /> leWe <br /> Awe crcf/,k/y �LuA!.f 1+ rw ii4-'14+-�P .fes <br /> cg �K VT c�a�c. .�..:�4 .%—� �iC 3 k pq 6e L/ y 7� <br /> (/ V o_Nx ostEnq <br />