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7 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES LFOR'LOCA `AGENCY U ONLY-- :>' '> <br /> REPORT BEEN FILED 9 t HEREBY CEFMFY THAT.);HAVE DISTRIBUTED THISINFDRMATION ACCORDING,TOTHE <br /> ❑ YES NO ❑ YES ❑ NO DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE SACK PAGE OF THS$FORM <br /> R/EPPORT OATS 1 CASE R 7 <br /> lJu� MI oof :SIGNED .`;DATE . .<'. <br /> tE � <br /> �INDVIDUA L FILING REPORT PHONE �l SIGNATURE/ <br /> 116,r"3 7 rf GGG-t�-P REGIONAL BOARD7. <br /> �!IPANY OR AGENCY NAME <br /> OVrNERrOPERA70R �. / `�� {-,ocr NCY ❑ OTHER �� _rCAcc SGf /i C7 GL tt + � S 7V 7G�Ll <br /> -CrtlY <br /> S,TV�STATE�!u <br /> y� <br /> ZIP <br /> PHONE <br /> NAME *q +�D <br /> P <br /> r <br /> i2 <br /> DSTAUT sa CONTACT PERSON <br /> UNKNOWN <br /> ADDRESS G .n 0,0,)t;q / frCITY P <br /> STATE <br /> FACILITY NAME(IF APPLCABLL) OPERATOR PHONE <br /> z 19 Tv o es <br /> u <br /> ADDRESS </ 141-1-7 <br /> CRY COUNTY <br /> STREET <br /> LLI <br /> CROSS STREET <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON =PHONE <br /> a�►T Da c l�r► Crr� /► H• <br /> LL,w PHONE <br /> REGIONAL BOARD <br /> da i 1 <br /> (1) NAME allANTITY LOST(GALLONS) <br /> w p ❑ UNKNOWN <br /> m z m I� <br /> rn <br /> 41 e4- /r7 Z�'t' /{1 %f 4- r r �E ❑ UNKNOWN <br /> DATE DISCOVERED H DISCOVERED ❑ INV RY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> ul ju [ Y ❑ TANK TEST ANK REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BEGAN [ METHOD USED TO STOP DISCHARG ECK ALL THAT APPLY) <br /> m <br /> aUNKNOWN ❑REMOVE CONTENTS CLOSE TANK 8 REMOVE ❑REPAIR PIPING <br /> w u al Y <br /> 0 HAS DISCHARGE BEEN STOPPED T _jREPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> U) t OTHER <br /> [:] YES ❑ NO IF YES,DATE u j p Yj v ❑REPLACE TANK OT <br /> SOURCE OF DISCHARGE CAUSES) <br /> auc LLJ <br /> ' ❑ TANK LEAK ED UNKNOWN ❑ OVERFILL ❑ R T[1RElFAILURE ❑ SPILL <br /> 0))v F-1PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w w <br /> CHECK ONE ONLY <br /> rn a <br /> Q ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w r7NO ACTION TAKEN F7PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> z <br /> U y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARYSITE ASSESSMENT UNDERWAY POST CLEANUP <br /> MONITORING IN PROGRESS <br /> REMEDIATION PLAN CASE <br /> CLOSED <br /> (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> ❑ ❑ <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> [sa9=>�ran OETA�FI <br /> 4 x' ❑ GAP SITE(CD)80 ❑ EXCAVATE b TREAT(E3� ❑ PUMP b TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w¢ ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REOUIRED.(NA) F7TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> m >r'C3/ Sfr i,� /e S i c�'r,S 7Z� /• y'#-o-A <br /> a StSS is..rF ✓r<// f •tP[SSS' �v/ <br /> 8 S ref"roe 1,y >2�.r lac.aC/ /r cj rit!fi f 1w 9 eC g e F s C <br />