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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 /> ❑ YES 0"�NO REPORT BEEN FILED? ❑ YES ❑ i HEREBY CERIFYTHATi.RAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTAI ITION SH ION SHEET ON THE BACK PAGE FTHIS FORM <br /> REPORT DATE LCASI a <br /> M V M IGNED c� DATE J <br /> NAME OF INDIVIDUAL FILING REPORT AA PHONE SIGN R— <br /> w REPRESENTI E-1OWNERA)PEATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> ¢ — <br /> S LOCAL AGENCY ❑ OTHER <br /> w ADDRESS <br /> /S749. $OJr zoos S�TGYY�7'o/J 4'i Z <br /> srnEEr cm HATE ZIP <br /> J NZ�r'- Jam^ � ��� CONTACT PERSON PHONE <br /> m IMYW ❑ UNKNOWN ( ) <br /> O� <br /> y ADDRESS <br /> 6rNo k -jA14,4v1\0 ,�c <br /> STREET CITY ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> .l-. CTeI Z- ) 369 -Rrs+ <br /> 0 <br /> ADDRESS6 144 <br /> w STREEr cm couNrr zw <br /> m <br /> CROSS STREET <br /> ST <br /> p LOCALAGENCYAGENCY NAME CONTACT PERSON PHONE <br /> lwJ�i,A�vrN Co- E1J✓rRauMFntr�L NfAcrN <br /> w <br /> w REGIONAL BOARD PHONE <br /> a wa ( ) <br /> NAME QUANTITY LOST(GALLONS) <br /> iw /�HvL�'i�( PT�`/1%�" Q NKNOWN <br /> D mThdi'ENE ,a) IPLPE/V2Enll <br /> � NKNOWN <br /> i DATE DISCOVERED gLCT HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> O M o W Y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP UNKNOWN ❑R MOVE CONTENTS ❑DISCHARGE PLY )❑ <br /> CLOSE TANKLR MOVE REPAIR PIPING <br /> III C)I DI YI Y <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK 8 FILL IN PLACE ❑CHANGE PROCEDURE <br /> SO o YES ❑ NO IF VES,DATE M M o Y r ❑REPLACE TANK ❑ OTHER <br /> -) SOURCE OF DISCHARGE CAUSE(S) <br /> j ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> mi CHECK ONE ONLY <br /> O ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER .(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK NLY <br /> w� NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTER2ATION <br /> ¢ ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O y ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(In <br /> 14EewK rw oET/i8) <br /> o ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP A TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w� <br /> w< ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) 1 <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> f0-o ll -7*vILRF/t 2NP! `I SotL corCL4AftA4#TrocJ. Do <br /> jti,¢THfEAe S,TA,< ,¢ F k7—iy�Y BEl ?v,P t� ?b �ETFiPi4tNE 'rp/ / ,,4rc"P£ U� <br /> N9c�Ieeq <br />