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00 6 <br /> UNDERGROUND STORAGE TA UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FON LOCAL AGENCY'.USE ONLY '. <br /> ❑ YES NO REPORT BEEN FILED? OYES ❑ NO DISTRIBUTIO1 HEREBY N SHOWN ON THE INSTRUCTIONS SSTRIBUTED HEET ON TTHETION BACK PAGE OF THIS DING TOTHE <br /> REPORT DA CASE i <br /> SI <br /> O O 0, PHONE SX;NFD DATE <br /> OM GN TUI RE <br /> NAME OF INDIVIDUAL FILING REPORT (�TURE T <br /> > LoR-I DvnjcAA) Prq) `{68033 <br /> O REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> SLOCAL AGENCY ❑ OTHER <br /> ADDRESSJo <br /> c <br /> 4 TE 21P <br /> 3O� � STREET <br /> Jy <br /> PHONE <br /> NAME CONTACT PERSON �ec9 <br /> )a,j 9 Ss�9 <br /> proct `hUNKNOWNZdl 1-0 <br /> ¢ ADORES Vk/VlG � q <br /> sIp <br /> • NxbSGE <br /> OPERATOR PHONE <br /> FACILITY NAME(IF APPLICABLY <br /> UADDRESS -"�-�b Lc uU s l S I� <br /> 3TREEf c� <br /> w <br /> CRDSS STREET _ <br /> y �nJ�EYL S I <br /> CONTACTPERSON PHONE <br /> G LOCAL AGENCY AGENCY NA'M'E Lo rz,I <br /> �" S01W� 1.lU� �a �KV• R�(/Tl1 `� I.J /VC.IVv l lOo <br /> zw <br /> w ti 'A^ PHONE <br /> M.w REGIONAL BOARD p� 1 �PJJ� - +��e I I 1 <br /> E< ��'V" ' "' '` � V / QUANTITY LOST(GALLONS) <br /> NAME <br /> y 0) UNKNOWN <br /> Q J <br /> m i (2) ❑ UNKNOWN <br /> yF DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ElSUBSURFACE MONITORING ❑ NUISANCE CONDITIONS O <br /> w ❑ TANK TESTJjZ; TANK REMOVAL ❑ OTHER O <br /> OMI SMI �I �oI r r METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> mDATE DISCHARGE BEGAN <br /> a UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> a <br /> w M M o o r r ❑gEPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> 0 HAS DISCHARGE BEEN STOPPED 7 <br /> VES ❑ NO IFYES.DATE r r OTHER <br /> REPLACE TANK ❑ <br /> O <br /> SOURCE OF DISCHARGE CAUSE($)F—] OVERFILL ❑ RUPTURE/FAILURE E] SPILL <br /> o"I I�T`UNKNOWN <br /> cy=i E] TANK LEAK ` OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> y ❑ PIPING LEAK ❑ <br /> ww CHECK ONE ONLY <br /> v UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> im LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY <br /> E] NO ACTION TAKEN ❑ PRELIMINARY S ❑ <br /> pff <br /> s? ❑ ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U'A ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSAflV) ❑ CLEANUP UNDERWAY <br /> ❑ REMEDIATIONPLAN <br /> CHECK APPROPRIATE ACTION(S) sFa EXCAVATE&DISPOSE(ED) ❑ <br /> REMOVE FREE PRODUCT(FP) E] ENHANCED BIO DEGRADATION(IT) <br /> I �1fOP°'"'sI Vis` PUMP 8TREAT GRO <br /> UNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> c ❑ CAP SITE(CD) ❑ EXCAVATE 8 TREAT(ET) ❑ <br /> ❑ ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> w< ❑ CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> A6 toca CoW� <br /> w <br /> lT <br /> E <br /> D <br /> U RSC PS IILs% <br />