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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICESFOR LOCAL,AGENCY USE ONLY <br /> YES NO <br /> REPORT BEEN FILED YES NO <br /> i}IEREBYCERTIFYTHAT I HAVE DISTRIBUD TH <br /> TEIS INFORMATION ACCORDING TO THE <br /> ❑ ❑ ❑ <br /> QISTRIBUTK)N SHOWNON THE INSTRUCTION s466Ww BACK PAGE Of THIS;FORM <br /> REPORT OATS CASE r <br /> q M 54 9 Y 61CiNED DATE; <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> > ` L. Un 1 (510 ) 8Lj;L- 5 <br /> ED <br /> w REPRESENTING e�OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> S ❑ LOCAL AGENCY ❑ OTHER ��V n P rO d 1►/('+S Cd m Qan <br /> ¢ ADDRESS <br /> T.0- 'Box. 5001 sa,n RumenIt <br /> C� a�is83-o$oy <br /> STREET <br /> cm STATE ZIP <br /> w NAME CONTACT PERSON 7PHONE <br /> z Q }�t.Vr Gr) r CO. ❑ UNKNOWN -bM /�� r ID 2-- 6 5 <br /> Oa as ADDRESS <br /> Lu P•d• fox 500y sari 4MOn, STATE °�y5g3-604STREET <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> Clevron Sccv�c,t S���toh #q—(og Chevron r�dvc�s Corr►Pany (sto )dkx.8b�t5 <br /> a ADDRESS <br /> 2yoq E- Mann S+rtc� S+ockb� , Citel Joitt <br /> ZIP <br /> wvin, A52v� <br /> STREET <br /> N CROSS STREET <br /> p LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> zq R o (APq )460-034'L <br /> w0cul pa tLy WA <br /> w it REGIONAL BOARD PHONE <br /> IL s ��1 ( r (qt -31 <br /> C <br /> Lu <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> v w UNKNOWN <br /> Z> <br /> m> (2) <br /> H? ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED --I INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w0 <br /> ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> O M /L 3 D Y Y <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> y UNKNOWN ❑REMOVE CONTENTSptCLOSE TANK 6 REMOVE ❑REPAIR PIPING <br /> WM D Y Y <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK E FILL IN PLACE CHANGE PROCEDURE <br /> Ln YES E] NO IF YES.DATE M ZD Y Y [:D REPLACE TANK E]OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> vTANK LEAK UNKNOWN ❑ <br /> y OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> ¢> � ❑ <br /> cO ❑ PIPING LEAK ❑ OTHER '0-CORROSK)N ❑ UNKNOWN O OTHER <br /> w w CHECK ONE ONLY ! <br /> U F-1 UNDETERMINED SOIL ONLY ❑ GROUNDWATER [:] DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z NO ACTION TAKEN F-1PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED Q POLLUTION CHARACTERIZATION <br /> ❑ <br /> "r ❑ POST CLEANUP MONITORING IN PROGRESS <br /> j ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY <br /> U y ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> REMEDIATION PIAN <br /> I •.�i(� ❑ ENHANCED BIO DEGRADATION(IT) <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE 6 DISPOSE(ED) REMOVE FREE PRODUCT(FP)❑ <br /> ISEt avert raR oer�aal <br /> ! a ❑ PUMP b TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Z CAP SITE(CO) ❑ EXCAVATE&TREAT(ET) <br /> 80 <br /> w a❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ¢ ❑ VACUUM EXTRACT(VE) OTHER(OT) <br /> Ior*'tc'�lv� al,c��o� �larw �Mplcr�tn�t�. Rcsvl+s of sot' an'klyses p"a)RO. <br /> w <br /> s 8 <br /> 1 <br />