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7 <br /> 61 �Q 6 l 6 <br /> -UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)!CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR{LOCAL AGENCY US ONLY <br /> 0 YES NO REPORT BEEN FiLEQ 7 YES Q NO 1 F€EREBY.CERTIFYTHA7 i )i11VE,DISTRIBUTEDTHIS i1JFQRMATION ACCORDING TO THE <br /> :._DISTRIBUTION SHOWN ON THE-U[STRUCTION SHEETON THE BACK PAGE OF THIS FORM <br /> .5GH 7: <br /> PORT CASES <br /> IED <br /> M MI V <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATL <br /> w REPRESE OWNEWOPERATOR r REGIONAL BOARD COMPANY OR AGENCY NAME <br /> RLOCAL AGENCY OTHER C' �1V <br /> ADDRESS <br /> _u L4 .E We-k-:&v- 3 Flop-r- &A (f(wt 1 <br /> STREET CfTY STATE ZIP <br /> w NAME y�+ CONTACT PERSON rPHONE <br /> V5 ^� + !1 Yr�S� a UNKNOWN l <br /> a a ADDRES <br /> 1 1 S STREET LIYY STATE IP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> a ADORES <br /> I rti E�+�� �" 7 3 � Ca ��jj Q , ,h l 5�� ., <br /> w zIP <br /> Ii= CROSS STREET p <br /> L AL AGENCY AGENCY NAME CCN TACT PERSON PHONE <br /> z <br /> LJ 0 r env ,I � � V Rle oltk ( 7�d4'1 <br /> w REGIONAL 80 RD + r� PHONE <br /> �¢ <br /> LU I NAME QUANTITY LOST(GALLONS) <br /> z w d 1 t 1--'r i�v�/ UNKNOWN <br /> �J <br /> Z (21 <br /> UNKNOWN <br /> w <br /> DATE DISCOVERED �j r1 HOW DISCOVERED Q INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> w D M! 1,3.1 J p y p �,y y ❑ TANK TEST TANK REMOVAL OTHER <br /> r <br /> DATE DkSCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M p y 5r UNKNOWN a REMOVE CONTENTS CLOSE TANK&REMOVE REPAIR PIPING <br /> w y <br /> p HAS DISCHARGE BEEN STOPPED 7 a REPAIR TANK CLOSE TANK S FILL IN PLACE 0 CHANGE PROCEDURE <br /> o X"YES 0 NO IF YES,DATE: I 2,111 I V v �v E]REPLACE TANK E:] OTHER <br /> M Mp <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> aTANK LEAK UNKNOWN OVERFILL 0 RUPTURE/FAILURE [D SPILL <br /> c V Q PIPING LEAK Q OTHER L] CORROSION ,UNKNOWN 0 OTHER <br /> Lu ww CHECK ONE ONLY <br /> UCL <br /> X�UNOETERMINED O SOIL ONLY Q GROUNDWATER E:] DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w NO ACTION TAKEN a PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> a <br /> cc y ED LEAK BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> U E-1 REMEDIATION PLAN F_� CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTIONS) <br /> ME MCK FQi DETu$I EXCAVATE 6 DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> Q <br /> Fn Z CAP SITE(CD) EXCAVATE 8 TREAT LLJ (ET} Q PUMP A TREAT GROUNDWATER(GT)Q REPLACE SUPPLY(RS) <br /> a CONTAINMENT BARRIER(CO) NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) � VENT SOIL(VS) <br /> cc <br /> VACUUM EXTRACT(VE) OTHSR(OT) <br /> z R � Lop <br /> Lu <br />