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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFF"OF EMERGENCY �COCA-AGENCY USE Y <br /> Q YES No REPORT BEEN FLED? p ji E6YCER YTNR��:HIWED15fR6t1TQJ'IHISM tAAildfA�00 tIGTOTI <br /> YES No <br /> p -AS1�u SHEETOOKAGE <br /> REPORT DATE C:ABE. 3- z <br /> NAME OF INDIVIDUAL FLING REPORT PHONE <br /> REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY <br /> /NAME <br /> 'AGENCY ❑ OTHER <br /> "ME OONTACT PERSON PHONE <br /> �/•S. p6dT of t uc.�' � p UNCNowN /e9YAr onl d 1-e fJ•ILEk I (4'/6) - 3 <br /> CL 2A00 _G Z,+ ST"�2�{ -T' lam/ X02,. �io.v�5 - 4S6l(o-54/7 <br /> _{ CITY A <br /> FACLRY NAME OF APPLICABLE) OPERATOR PHONE <br /> 4" S®jL GonJ f,.� .yiGF (Obq )7 Z 7- <br /> Aal Al- EGoGKF_F,o�j S, . f� 4couw" g7Z3-7 <br /> WNWzr <br /> CROSS STREET <br /> Arco�i3O`a R o.4t� <br /> Q LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> REGIONAL BOARD PHONE <br /> I �� (T/P�c.�. �7N•'�nlr/J = NAME QUANTITY LOST PALU0613)NOWN <br /> = DATE DISCOVERED HOW DIsiCOYER� ❑ W49MM OONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> D ❑ TANKTEST 2—uw REMOVAL ❑ OTHER <br /> DATE OIBCHARGE BEGAN r METHOD USED TO STOP DISCHARGE PIEC K ALL THAT APPLY) <br /> (NpWN ❑REMOVE CONTENTS [:]CLMC OSE TA3 REMOVE Q REPAIR PPM <br /> HAS DISCHARGE BEEN STOPPED? Q REPAIR TANK ❑CLOSE TANK i FILL N PLACE p CHANGE PROCEDURE Lk <br /> ❑ YES ❑ NO IF YES.DATE p REPLACE TANK p OTHER <br /> y� SOURCE OF ON 34AAW GMJSE(B) <br /> ❑ TANK LEAK 2<mooWN ❑ OVERFILL ❑ RUPTURE/FAILURE Q SPILL <br /> ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNN om ❑ OTHER <br /> W ONECKONEONIY <br /> ❑ UNDETERMINED g SM OfLY ❑ GROUNDWATER ❑ DRNKNG WATER-(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ON.Y <br /> ❑ NO ACTION TAKEN ❑ PRLE.l waw sm ASSESSMENT WORKPLAN SUBMITTED p POLLUTION CHARACTERIZATION <br /> ❑ LEAK BEING CONFIRMED p PRELIMINARY SITE ASSESSMENT UNDERWAY p POST CLEANUP MONITORING N PROGRESS <br /> p <br /> REMEDIATION PLAN p CASE CLOSED(CLEANUP COMPLETED CRL UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> 04ECK APPROPRIATE ACTION(S) ❑ S=AVATE i DISPOSE(ED) p REMOVE FREE PRODUCT(FP) ❑ &*0NCED BIO DEGRADATION(M <br /> pnMmc Mem"Am <br /> Q CAP SITE LCD) p L'mAVATE i TREAT(En Q PUMP a TREAT GROUNDWATER(GT)p REPLACE SUPPLY(RS) <br /> ❑ <br /> CONTAINMENT BARRIER(CS) Q NO ACTION REQUIRED atv ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOL(M <br /> ❑ VACUUM E mv=(m Q OTHER on <br /> �iEv/Esv of S�'�L�''biv�-7`S F.�•vr-� ?f ls�[1G-/t�o+�''�•. T.rd o�a.t�� �.lc.LAIN �( <br /> W �i4'1f,�G°.e.° s'✓'�2il�iG�► 4"1` 4i/`L .Gid �GEO✓� °/�1 7D L�lE/��4tNL ?T5� <br /> Aak7f^rrr ,o!,C <br /> ?S Nsealmw <br />