f •UN
<br /> DERGROUND y.._,u., ,..,�..�,; - �..,•tea.-,�_.T,�...�,....,..�r. .��
<br /> - ;. . : _ STORAGE TANK UNAUTIORIZED RETE_ASE^(IrEAK)1 CONTAMII`fAT10N�
<br /> Sl
<br /> EMERGENCY-E4 EMEAGENCI"v
<br /> HAS STATE OFFICE OF EWERGENCY'3�V�S � � .--
<br /> r
<br /> - r REPORTS FILED 7 - FDR LOCALAGENCY USE ONLY :
<br /> YES is ' xtt0�` r" n YES'Q tya " ^ 'E'NEREBY CI fTTIFI 7HAT I AM A��53C7lATE(1 GOYEAII�AFJ(I EMPLOYEE AND THAT.!HAVE
<br /> '. ::. . 0
<br /> I. RE?ORTDA �.-. , _ - R�EP�� THIS-INFORMATION TO LOCAL C1FF)CIALS PURSUANT TO SECTION 251847 OF
<br /> TH AND 5AFT1 CODE
<br /> 1 NANE OF INDIVIDUAL FLING REPI]RT 'N
<br /> i) tt •.r _5t w C n r -t C 1 P�HfON6 T r SIGNATLNRE sm OITE
<br /> Ir m� - G Yt O �b �`S —w.Y� .� .. .:1... mer {Z.x)'•� _ _ '.
<br /> o
<br /> REPRESENTING yy� „7 _
<br /> �r h_„N +,a❑ OWNER+OPEAATOR �'.;REGIONAL BOARD COMPANY OR AGENCY NAME
<br /> ` O �TOCALAGENCY ❑ OT7 EA r . ...,
<br /> ADORESS�Yr”`CL
<br /> t„ysC�r1*F'vi •-'V-
<br /> in-
<br /> 2-
<br /> •'r ' `�+7 t �Y i1 � yr N r , -� r•- i � ` 7.-•, S .}+••+`--►*'{l,-� o:►.+}I:t;+�i;�.l� 1 �J.
<br /> r - , Pte. :alt ..:� ";�. ; 2yc� :�•,,.� .$�-1?aR�..;r.; , _ ''. - + �'.a.--R.J .! `rcf52- - -
<br /> 'ol
<br /> T �> [_iI .?x^l : • a • �� y c n+y. CONTACTP
<br /> I / .. ;' .•• :c.r t: 1,� a _ m � � ,v 'PHONE
<br /> z�. A�,O _ E;y:!+'a+x a =C b e c' ! :� W!Q!OWN � s t 7
<br /> 4ADDRESS _ euvc v4__ : w�-
<br /> o „
<br /> .. ..
<br /> I yd
<br /> l y •� t/l ..>.+ gEET ><k .L� - -.1Y.� r • �"S�.�C��Y S �'L.�-•Y;�'V M h -• V f.c,
<br /> r FACtsT1 NAAiE(IFAPPLICABLE) r p� ST
<br /> T ' av
<br /> Z �DRESS
<br /> r, ` r_ _ PHDIJE�'-I�KCG 'V,y[ �,. :Q�• 1.M IID t' `1 �4/ YJPVJf l�V4 �LLF•1 cf
<br /> C, CROSS STREET'-.:Zr rfv cou n
<br /> TYPE OF AREA {
<br /> - COMMERCIAL PNDUSTR TPE OF
<br /> ❑ U1L BUSINESS
<br /> ❑ AURS NESS
<br /> . ❑ RETAIL FUEL STATION -
<br /> r?SpRES�ETITUL" OTHER
<br /> ! LOCAL AGENCY. FARM�r QTHER: - t
<br /> I rn T y ;r.AGENCY NAME CONTACT REASON
<br /> z� c-.,� ^ r� L��a:i .. �e�i`'��,�`=�� k `t.. -L.��..',c- G.�-� `��G0�°� � h�•(� .
<br /> jl REGIONAL �' ►12�`-.. I
<br /> 3'6 r-
<br /> NAME
<br /> CUANTTTY LOST(GALLONS) I
<br /> DATE DI ❑
<br /> UNK
<br /> N
<br /> ower
<br /> Il' SCOVERED .
<br /> I. w �•rr "r, ., HOWOISCGYEAED. WVENTORYCONTAOL SUB FACE MONITORING a�
<br /> 3 - .. NUISANCE CONDITIONS
<br /> �Y Ff v ❑ TANK REMOVAL . ,' .❑ DTHEA
<br /> DATE DISCHARGE BEGAN _• METHOD USED TO STOP DISCHARGE(CHECK ALL THA APPLY
<br /> ::
<br /> �• .'.t z -- a .._ -
<br /> u¢e u "y ..p.., .p .. r r- �NKNOWN ❑ REAIOVSCQNTTNIS REPLACE TANK
<br /> HAS DISCHARGE BEEN STOPPED 9.-,:9 t t„ 4 ❑ OSE TANK'
<br /> ,� REPAIR TANK - ❑ REPAIR PING �j y O CHANGE PROCEDURE; ,
<br /> B n5 NO'"IFYES.DATE pu� u� �p�`Vp� �Lr�^ �r ❑ OTHER
<br /> Lu SOURCE OF DISCHARGE --- -
<br /> h TAIrKSONLY.C.WACITY MATERIAL' " CAUSE(s)
<br /> _
<br /> ( :❑ TANKLEAIC "�GNKNQWN' va 'r ' GAL C ❑ IS O ERFlL 4 , ALURE
<br /> U Y ` ❑� .v .RIPTURE�F
<br /> r4 ¢ s PIPING LEAK e r y a
<br /> r -5. ._ _�_• R o-rwg�y'�TE0., vt �. - ^ ,CORROSION TM p(]Zpy,j,rt�"'T•;• I
<br /> UNKNOWN �r y r T� ,;u.r❑ OTHER fl ` t Q SPIEl?�Q OTHER.
<br /> TH
<br /> EA
<br /> ty ty CHECK ONE ONLY n" .-.•r ._ _ = --�—4
<br /> I - U 'LINaEI'ERMWED 'y�0 �- .r, �... •a,•.:-.µ'�,T .: s .z. .-, + .v.r,,4;- .�_. . -
<br /> ❑ GROUNDWATER -❑ ;DRINKNG WATER_= (CHECK ONLY F WATEA WF1 I S HAVE ACTUALLY BET]1 AFFEC ^ -
<br /> ` i U) CHECK ONE�ONLY�q�r!},'.'qrr t� r.r :, .r±::'i- er ^;4 r�;:; -•r
<br /> ' a R ' Q SITE tWESTIGAT1pN fN PRnGRE55
<br /> (DEFWNGEXTENTOF�ROBLECLEZUPINPROGRESS SIGNED OFF '; �v`
<br /> • r (CLEANUP ,
<br /> MONITORING W PROGRESS '.C�iM7 FrUNDS AVALABIE TOP �5�
<br /> -r '— _ _... .., ROCEED:y;Q I1/AIJ1A71NGCLEANTAI-TEWVATTY&S
<br /> [NECK??PRO?RIATEACTION(S)(SEE BACK FORCETAILSI- Pt r..• , �i..� yi. .�_,_ ,,., -x y c,
<br /> .._ •:.,F.�;-r..L .....-. 'p-v.i ' - w:. :p XY,;. i•Ta� .t,-. ;!, -� _'p'!ir ?r' ,` Z ` c;:;.. i"-i's ... ,
<br /> °❑'CAP SrTE(CD) +. )+ . y x s l'•u�ra ..s ' `,; !ss: ° .e�' �cJ�,+e ai. d1;,f'
<br /> + ,r -- 2x x r r•m r EXCAVATE t DISPOSEtA'EMOVE FREE PRW_ T(FP] -� gRANCEO BIO DEGRADATION
<br /> 't.
<br /> �.•+. ;r OON'TANNM N`SA (CO)'
<br /> •+4.a.t ATF&: �.1Ra�rf.j s+. Ducap�.+ .r.,.•v. _-.v.,..rw.?.{u�- .. ti•+:w...�., '. ,.�;«r.` ,y;<
<br /> 'F ENT BARRIER CEXCAVATE Nk TFiEA7{E7) « _ � PUMP&-TREAT GROUNDWATEA.(GT) REPLACE SUPPLY
<br /> y
<br /> ❑
<br /> TREATMENT AT(IOOKUP(1 N N) _.
<br /> _ NO ACTION REWIRED(NA) .'OTHE (OT). _ - +
<br /> w v! vi;uy
<br /> S `
<br /> € I
<br /> I
<br /> MSC ix3
<br /> Tush
<br /> I� H
<br />
|