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1)9 - <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES „FOR`LOCAf.AGENCY:USE ONLY . <br /> REPORT BEEN FILED i <br /> [] YES NO ❑ YES ❑ NO 1HER�BY,CEH]}FYTHA7.}HAVIEDISTRIBITTE . [H 'INFOAMATIOPIACCORDUIGTQTHE.` <br /> ::DISMEUTION'SHOWN(CN.THE.INSTRUCTI)N SHEET.ON:THE.BACK PAGE OF.THS FOFihI <br /> REPORTDATE <br /> CASE x ::... ,. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> >- r t -0 M ) 1463-3L(ni <br /> L'u' AEPREsENT4d OWNE BATOR ❑ REGIONAL BOARD COMPANY OR�AGENCY NAME <br /> ] <br /> g LOCAL AGENCY ❑ OTHER ��bi)C f e-4, -til_C,_.r J(Cel u t rG n ht r!CQ <br /> Cc ADDREss <br /> 3p E . Lc���r fid- Poor 3-Fac--Iq'v�, CA- <br /> w C" STATE <br /> NAME /�,, ! CONTACTPERSON PHONE l Q <br /> z [ g e.-t�( rS Qrc A rd ❑ UNKNOWN I�r L �j �Q ell (C�HO" 9 35 "�7 <br /> a <br /> 00 a ADDRESS <br /> 6 <br /> ]� �( va-ra.(,s C� -gS.38S <br /> w (J S <br /> srREST Mysr.TEZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> e 'S Qrcarc� c vlce A 1b&rfir48`l 7 <br /> U ADDRESS �3 3 V P.( o& i S 4 r _4538.5 <br /> w <br /> � 3 <br /> y CROSS STREET <br /> O L�� AGE `NAMEC CONTACTPER$ON PHONE- O0. [v1 k !DD <br /> Z w r il (E�pJY-3 yfl <br /> C=3-,%j ro <br /> w w REGIONAL BOARD PHONE <br /> a <br /> a <br /> (I) NAME QUANTITY LOST{GALLONS) <br /> U d sa l t • L� UNKNOWN=W a <br /> �O m <br /> N 7 - <br /> �2 <br /> y ❑ !UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> z <br /> w O 'r` o l r 1 r ❑ TANK TEST TANK REMOVAL ❑ OTHER o <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) V <br /> m <br /> g <br /> UNKNOWN ❑REMOVE CONTENTSCLQSE TANKS REMOVE ❑REPAIR PIPING <br /> w Mf D <br /> HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK 3 FILL IN PLACE ❑CHANGE PROCEDURE <br /> o YES [:] NO IF YES,DATE v�o `? r r ❑REPLACE TANK ❑ OTHER Q <br /> 'I SOURCE OF DISCHARGE CAUSE(S) i,, r'' <br /> a ❑, TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPRL I� <br /> N ❑'"PPING LEAK OTHER ❑ CORROSION_ UNKNOWN ❑ OTFIER <br /> y a CHECK ONE ONLY <br /> cai UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) ` <br /> CHECK ONE ONLY "•:T- <br /> z0 ❑ NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED C::] POLLUTION CHARACTERIZATION - <br /> r ❑ LEAK BEING CONFIRMED PRELWINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONIMRNG IN PROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> f� <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 5 DISPOSE(ED) ❑ REMOVE FREE PROOUCT(FP)' ❑ ENHANCED BIODEGRADATION,(m <br /> a <br /> ❑ CAP SITE(CD) ❑ EXCAVATE 3 TREAT(ET) ❑ PUMP 6 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ?~ <br /> 250 <br /> Lu a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REOUtRED(NA) ❑ TREATMENT AT HOOI[UP(I-" ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(CM <br /> y 5� � . W[ l be �t�c�d c h L-ocOL( 0 ue..rs <br /> . p�}ar� ���-�- � t n�3�s�t g cr.*.� ec�•ta-F�€�-, L� - <br /> Wr <br /> r+scosl�m- <br />