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4h, 0'06 147v <br /> 4 UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES YES <br /> USE ONLY <br /> Q YES NO REPORT BEEN FILED 7 - <br /> j Q <br /> YES NO EHRFYTHATI HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THER PORTDATE - CN SHOWNCN THE.INSTRUCTION SHEET ONTH a.._� M- <br /> TD 'V CASE }�''�(/] <br /> IUi` 51.. � � <br /> r SGNED. DATE <br /> NAMEOF INDIVIDUAL FILING REPORT ,I PHONE SIGNATURE nnn -I <br /> 9 FifR 1 <br /> m <br /> REPRESENTING COMPANY OR AGENCY NAME <br /> OWN RIOPERATOR O REGIONAL BOARD E/(}t,,.,,� <br /> S .❑ LOCAL AGENCY O OTHER PIYSN� <br /> ADDRESS <br /> W IT/SERVICES <br /> - WL�CJ VVV� ��=�� <br /> is <br /> srReer cm srAre R <br /> w E V <br /> CONTACT PERSON PHONE <br /> II <br /> atj itsm ' <br /> i a UNKNOWN <br /> ADDRESS <br /> - <br /> R I <br /> o DO <br /> a <br /> N I <br /> W �///�/� <br /> REEF 1�/� Cm STAT£ 9/5-D IV �F <br /> FACILITY <br /> 'onNAME <br /> a(IF APPLICABLE) <br /> �� /\ II OPERATOR PHONE <br /> O <br /> U ADDRESS - ( ) " •� <br /> w Wa k & Gt{/lV RfEf trtr `lGl.7 L vD `C NTr R . <br /> CROSS STREETmms <br /> y :I <br /> O LOCAL AGENCY AGENCY NAME 7 TACTPERSON PHONE <br /> H . II o I meq) �{GK 3'1 <br /> W 7o f OV.t V;r , . I L). ISG t"1 <br /> ( <br /> HZ <br /> w REGIONAL BOAR "' �I PHONE <br /> < Cor( co n I& )2s 5-351q <br /> 1� NAME QUANTITY LOST(GALLONS) <br /> Z' T6 L) G� : L vi16ev\2 ftTQ <br /> � e�le5 UNKNOWN. i <br /> m i F�) I� ilC rz <br /> P1 1 T j.� <br /> t ^I UNKNOWN.. <br /> i <br /> DATE DISCOVE/'/1R�ED HOW DIS VERED O INVENTORY CONTROL SUBSURFACE MONITORING Q NUISANCE CONDITIONS <br /> w 'OW M ` D O o o v 3 Y TANK TEST TANK REMOVAL OTHER <br /> QDATE DISCHARGE BEGAN Ij I METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M D r +. rCINKNOWN REMOVE CONTENTS O CLOSE TANK B REMOVE OREPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 4',E REPAIR TANK IE]CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> a I'D YES Q NO IFYES.DATE M I ',p r r REPLACE TANK OOTHER <br /> SOURCE OF DISCHARGE W CAUSE(S) <br /> ¢j „❑ TANK LEAKUNKNOWN ❑ OVERFILL RUPTURE/FAILURE Q SPILL <br /> v <br /> PIPING LEAK 10 OTHER �I O CORROSION UNKNOWN O OTHER <br /> ww CHECK ONE ONLY u - <br /> N y <br /> GROUNDWATER DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> UNDETERMINED EJFill SOILONLY <br /> CHECK ONE ONLY ' <br /> a� '1���-O-yy-y�(( NOACTIONTAKEN a, PRELIMINARY SITE ASSESSMENTWORKPLAN SUBMITTED O POLLUTION CHARACTERIZATION, <br /> j~ LEAK BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> Ow <br /> REMEDIATION PLAN F--j CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) �I. O EKCAVATEB DISPOSE(ED) REMOVE FREEPROOUCT(FP) O ENHANCED BIODEGRADATION(IT) i <br /> fsg Sr,Rswo[iiunl <br /> o p CAP SITE(CD) EXCAVATE d TREAT(ET) PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> CONTAINMENT BARRIER(CB) NO ACTION REOUIR D(NA) TREATMENT AT HOOKUP(HU) VENT SOIL S) ' <br /> I,O VACUUM EXTRACT(VE) —tROTHER(OT) <br /> rY10�1 l i <br /> oMwc C3e�I:<w e - 23.u,6/L � wax"To,i v eh e 3-3 uJ/�-, art zel�e Awr= Ii I <br /> vna s TGta\ icy lev.es,'= 275- z4; /Nair NIT GE = 48 �/L . /fix D I PC :-q.7 <br /> ��L <br /> Max -r P�1 5 29oo a4 RSG 0519M <br />