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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY.USE ONLY <br /> YES NO YES NO <br /> REPORT BEEN FILED 7 i HEREBY;CERTIFYTHAT).RAVE DISTRISUTEDTHIS INFORMATION ACCORDING TO THE <br /> ? <br /> :.DISTR IBUTICN SFIQWtJ QN THE 1MSTRUCTION:_ ON THE BACK PAGE OF TH FORM. ;- <br /> REPORT DATE CASE t <br /> �ull <br /> 3.1 L`.d r :7 SIGNDATE.:: .... ' <br /> NAME OF INDIVIDUAL FILING REPORT PHONEI RE <br /> I m SOS lD (Zn) -144&-6 3't <br /> w REPRESENTINGa OWNERlOPERATOR L] REGIONAL BOARD COMPANY OR AGENCYNAME <br /> g2 LOCALAGENCY OTHER <br /> ADDRESS <br /> STREET C" STATE ZIP <br /> I w NAME CONTACT PERSON PHONE <br /> oa 44-'�,�. ylC.�1 uNxNowN <br /> If a 1tk <br /> Lu <br /> STREET CTTr STATE ziP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> a AD{R5 S ` <br /> QS3 11,. I <br /> J STREET C GOU <br /> w P <br /> CROSS STREET <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> �w <br /> w w REGIONAL BOARD PHONE <br /> as CLVfZ , } <br /> � Lv t <br /> (�) NAME QUANTITY LOST(GALLO <br /> tu <br /> L)w UNKNOWN <br /> Z V �J <br /> a 1 <br /> mZ ; i <br /> y a UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED INV TORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> uj TANK TEST TANK REMOVAL OTHER <br /> I c DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL TF{AT APPLY) <br /> UNKNOWN REMOVE CONTENTSIKCLOSE TANK L REMOVE 0 REPAIR PIPING I <br /> ? HAS DISCHARGE BEEN STOPPED 7 r 0 REPAIR TANK CLOSE TANK 8 FILL IN PLACE [:]CHANGE PROCEDURE <br /> I I <br /> 4 YES ❑ NO IF YES.DATE �I r D rr REPLACE TANK ,❑OTHER <br /> 4 SOURCE OF DISCHARGE CAUSE(S) <br />! L w <br /> L)Z, ❑ TANK LEAK UNKNOWN OVERFILL RUFTUREIFAILURE SPILL <br /> w V F-1 PIPING LEAK ❑ OTHER CORROSION IN UNKNOWN a OTHER <br /> w w CHECK ONE ONLY <br /> rn a <br /> v ❑ UNDETERMINED SOIL ONLY GROUNDWATER Q DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z Q NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> cc <br /> cc LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> U F-� REMEDIATION PLAN a CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED 810 DEGRADATION(IT) <br /> Ise anon FCA DETOAM <br /> a z CAP SITE(CO) EXCAVATE 8 TREAT(ET) PUMP 8 TREAT GROUNDWATER(GT)E—] REPLACE SUPPLY(RS) <br /> 80 <br /> Lu <br /> Lu a F7 CONTAINMENT BARRIER(CB) C:] NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> d <br /> I <br /> 0 VACUUM EXTRACT(VE) 0 OTHER(OT) <br /> PICenc- <br /> K=asIbF <br />