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U <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY 9 <br /> tYES �v_ REPORT BEEN FILED? RLOPALAGENC]f SSE��+ NOYES 0NOGT .THAW 1 ANE A pES1GOYAN�IEt' MPREATE�x FORMATSECT��CASE#E OF INDIVIDUAL FLING REPORT <br /> PHONE SIGNATURE <br /> DATE:.: <br /> y <br /> LJAV k ;iAli3tesl3 <br /> t �+U9) XrJi1 r <br /> q REPRESENTING OWNERIO_PERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> FO ❑ LOCAL AGENCY ❑ OTHER LglAri1J L'.G. <br /> ADDRESS <br /> li6ki N'.:;`SC L.nckeloid Ci t at LLui Com, 95140 <br /> SIRE Cn'Y STAT£ �p <br /> NAMECONTACT PERSON <br /> 9 i r1ffUL: C. ',}fi�tL�3 CO.' PHONE <br /> :�,�v t;�tiR��.3 Coy. y 334-u 0 <br /> ❑ UNKNOWN <br /> a ADDRESS <br /> Lu iriJ�1 r:1:3C (.C7i:eGu-Ord� :►Cfce:L Lod i �:i► 93«i4(1 <br /> ac , <br /> STREET orry <br /> FACILITY NAME(IF APPLICABLE) OPERATOR STATE � <br /> CL-EMEPiTS ROCK 111"ANTLn PFNONE <br /> _CLAU;1r L;. '( A C(1. �C)� 159--3331 <br /> ADDRESS c. <br /> L i ,3U0 JNi1ixtit F,oa'd. t~'Ltrr ,� Sax) .juaqu i a 95,, 7 <br /> " STREETS <br /> w CROSS STREET TYPE OF AREA <br /> ..•:1[v i� Il's $.(TFsiE ❑COMMERCIAL❑INDUSTRIAL❑RURAL 3FA <br /> OFSUSINESS ❑ RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER RM ❑ OTHER =4 U:'s 1 1'j, <br /> LOCALAGENCY ' AGENCYNAME CONTACTPERSON PHONE <br /> W ::1: .J<JtN tii11i9 (� .(, il� .�',.T;V.•t,FU�ilYiull Z:.i i t' <br /> REGIONAL BOARD PHONE <br /> (1) <br /> LU NAME <br /> QUANTITY LOST(GALLONS) <br /> � :',�uaul�tu� <br /> (2) ❑ UNKNOWN <br /> ❑ UNKNOWN <br /> TE�ISCOVERLED C) 1 NDWDISCOVERED ❑ INVENTORYCOVTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDMDNS <br /> M ft p p Y y ❑ TANK TEST ® TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THATAPPLY) <br /> }� <br /> mi mi Di Y yjE] UNKNOWN REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIR TANK ❑ REPAIR PIPING © CHANGE PROCEDURE <br /> 'p ❑ YES ❑ NO IFYES,DATE (i 1. 1 E:] OTHER <br /> M M D D Y Y <br /> SOURCE OF DISCHARGE = TANKSONLYr—APACITY MATERIAL CAUSE(S) ' <br /> TANK LEAK ❑ UNKNOWN 5,000 <br /> GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FANLURE <br /> El PIPNNGLEAK AGE� YRS ❑ STEEL ❑ CORROSION ❑ UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> Lu CHECKONEONLY <br /> ❑ UNDETERMINED 0 SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS 14AVEACTUALLYBEEN AFFECTED) <br /> H CHECKONEONLY <br /> a 0 SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> `� ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS._❑_No FUNDS AVAA ABLE,TO PROCEED - ❑ EVALUATING CLEANUP ALTERNATIVES- <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD)ui <br /> ❑ EXCAVATE S DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 810 DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE NRTREAT(ET) ❑ PUMP4TREAT GROUNDWATER(GT)) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT ATHOOKUP(HU) ❑ NO ACTION REQUIRED(NA) OTHER(OT) <br /> F <br />