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9 0 qr-u83 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCYO VES �NO <br /> HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ VES N <br /> REPORT BEEN FILED? I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> -0ISTR TION SHOWN ON THE I STRUCTK7N SHEET O E ACK PAGE OF THIS FORM <br /> REPORT•DATE q/ 9 CASE• <br /> OM t,/ M ✓ / /Y SIGNED d DAATE.. <br /> NAME OF INDIVIDUAL FILING REPORT PHONESIGN RE <br /> L INF <br /> w)&gw � <br /> rein <br /> w REPRES TING COMPANY OR AGENCY NAME <br /> F [] OWNER/OPERATOR REGIONALBOARD <br /> g LOCAL AGENCY Q OTHER <br /> ¢ ADDRESS <br /> �A//J�� 9 <br /> ♦ 10 (NoSTREET CT' STATE <br /> w NAME TPERSON PHONE / <br /> Z, <br /> d[ ❑ UNKNOWN tr✓CGl-C.�� (I/S I / d`- <br /> yn ADDRESS /�j <br /> STREET CITYVCf/YL STATE <br /> ¢ <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> #,a/(,8 ( ) <br /> ADDRESS <br /> w S SREE � Cm <br /> COVN"I.5 <br /> y CROSS STREET <br /> /-//v Coen/ <br /> O LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> Z //140CU eN4 6Phs <br /> w r. REGIONAL BOARD PHONE <br /> ✓a LLs /PE6. 6 Gs 6. t 9/te) 36/5600 <br /> y (1) N NAME /� QUANTITY LOST(GALLONS) <br /> Z w ZO 3 (5 1#15 /15UNKNOWN <br /> F J <br /> m Z (2) <br /> N <br /> 0 UNKNOWN <br /> i DATE DISSCCOVERED 9 HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> u1 O u O o T v / Y E] TANK TEST O TANK REMOVAL OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> dNKNOWN REMOVE CONTENTS O CLOSE TANK&REMOVE E]REPAIR PIPING <br /> w u o r r <br /> W> HAS DISCHARGE BEEN STOPPED? REPAIR TANK O CLOSE TANK&FILL IN PLACE O CHANGE PROCEDURE <br /> 8 <br /> 6 0 YESj NO IFYES,DATE Ml u o Y1 Y REPLACE TANK QOTHER <br /> SOURCE OF DISCHARGE CAUSES) <br /> 1w <br /> F-] TANK LEAK UNKNOWN � OVERFILL RUPTUREIFAILURE 0 SPILL <br /> wo O PIPING LEAK O OTHER O CORROSION EvNNKNOWN O OTHER <br /> qww CHECKONEONLY <br /> O ❑ UNDETERMINED dSOIL ONLY GROUNDWATER 0 DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> ?� O NO ACTION TgKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED Q POLLUTION CHARACTERIZATION <br /> w <br /> M;5 F--] LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> O F REMEDIATION PLAN 0 CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) 0 CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) Ej REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> J I�aclt iCAOETNs1 <br /> a p ❑ CAP SITE(CD) Ej EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> w <br /> wa � CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) E] VENT SOIL(VS) ' <br /> VACUUM EXTRACT(VE) F-1 OTHER(OT) <br /> / T/l %/"CJ C�YX/C.It�Ta4 e. <br /> Z / <br /> CLQ l� c�r <br /> 8 J <br /> NSC M(MO) <br />