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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES - <br /> J REPORT BEEN FILED z FOO LOCAL AGENCY USE ONLY <br /> ❑ YES U NO YES D NO 1 HEREBY CEHTIFYTHAT I HAVE DISTRIBUTEDTHIS INFORMATION ACCORDING TOTHE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF.THIS FORM <br /> REPORT DATE CASE £ <br /> 0.1 60MI � O � Y SIGNED I IN DAZE <br /> NAME OF INDIVIDUAL FILING REPORT II -- PHONE %IONATNaV <br /> Ai 08- o33S Q5101 COQ <br /> REPRESENTING <br /> F-1 OWNER/OPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NA E <br /> p LOCAL AGENCY E] OTHER <br /> a�RESS <br /> Dy OGr 1 (kTrd Floor D <br /> �toa)c4on CWSTATE ZIP <br /> NAME s+1 CONTACT PERSON PHONE <br /> 5 �� � J 0jr NAS ❑ UNKNOWN ` y ` O IT (yLOq ) <br /> 0 a ADDRESS <br /> Nd <br /> PEEclw STAZIP <br /> FACILITY NAME (IF APPLICABLE) OPERATOR PHONE <br /> p <br /> ADDRESS <br /> s 1325 Corro , qao, Scuv',.So �Y Wvu q %S <br /> ZIP <br /> - CROSS STREET <br /> ra%& <br /> O LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> Som uiMCo rjow 1�In ct r -` onvNLok4 (2csZ) �{ 1o$-o33S— <br /> w REGIONAL BOARD - PHONE <br /> 7 <br /> Ea ( ) <br /> NAME QUANTITY LOST (GALLONS) <br /> > Ul � �� K <br /> UNKNOWN <br /> m > (2) <br /> N Z ❑ <br /> UNKNOWN <br /> F. DATE DISCOVERED �'7_ HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCECONDITIONS <br /> "'�1.1I (061 001 Dlq YI Tr ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> M M o o y y UNKNOWN ❑ REMOVE CONTENTS CLOSE TANK & REMOVE OREPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE <br /> U o `�VES ❑ NO IF YES. DATE (OMIdp 2 VI <br /> TY ❑ REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSES) <br /> ow ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREFAILURE _jSPILL <br /> 00 ❑ PIPING LEAK F-1OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w CHECKONEONLY <br /> U UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wM F-1NOACTIONTAKEN F-1PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ¢ a ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U y O REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (170 <br /> J� WXr o A� <br /> 0 o ❑ CAP SITE (CD) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br /> WO ❑ CONTAINMENT BARRIER (CB) NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) VENT SO IL (VS) <br /> a <br /> ❑ VACUUM EXTRACT (VE) ❑ OTHER (OT) <br /> M, iz" �+J^c . � c asscssuA �A.t w . ( ) foG At� uraKd do a wun `_ <br /> P2 <br /> ✓k4cL+uoc. nxt� C�cEcu of Cbvic+4-LuuvLq,+toti o. % relulVc./c bt( v -C" <br /> owro pmk4c, L �LaJov% cvL C�•1 , l <br /> AmuAl <br /> KSC 0. (89U) <br />