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. 4 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF 5ME13GENCY SERVICES ;FOR LOCAL'AGENCY sUSE ONLY <br /> REPORT BEEN FILED 7 .1 HEREgY.CEFMF.YTHAT i HAVE OISTRIBUTEb THIS INFORMATION ACCORDING TO THE <br /> ❑ YES ® NO ❑ YES ❑ NO DISiR13UTi0N SHOWN ON THF INSTRUCT 'SHEET ON THE BACK PAGE OFTHIS.FORht <br /> REPORT DATE l ! FCASE iy� � <br /> G�eI 9M� y I SIGNvED►�+� DATE. ... <br /> NAMEOF INDIVIDUAL FILING REPORTPHONE- SIGNATURE <br /> REPRESENTING F-1REGIONAL BOARD COMPANY OR AGENCY NAME - <br /> O W NERlOPE RATOR <br /> ¢ ? LOCAL AGENCY ❑ OTHER <br /> a <br /> s Lu ADDRESS /V/]fr�F]r��J} <br /> 1 1 L/ REST V V CrtY IJC./ �, ✓'' STATE 3ZIP - <br /> NAME ,,�� r) A <br /> CONTACT PERSON 1 ) rPH�ONE Y7 �]�1 <br /> ED <br /> J�7lj U KNOWN i.�liJT 1 �/Y 4� �I� / / r✓ <br /> 00 ADDRESS D dd �( Q -�7 J7 <br /> - � <br /> ¢ { I rJ �/' 1! / v em <br /> STREET <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> a ADDRESS <br /> O J STREE7 COVlJTY 943 <br /> w <br /> y CROSS STREET <br /> WAWA 4- <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> Z aof 2,0 <br /> Uj U <br /> w wREGIONAL BOARD PHONE I, <br /> a G ti/,� G�✓ � c�/6�3r I—S� o <br /> m (_) NAME OUANTITY LOST(GALLONS) <br /> Lu <br /> a W /`U�`P�/L V1.ti ` ` U >f�� T� ��� ❑ UNKNOWN <br /> r U <br /> ym z (2) I: <br /> UNKNOWN <br /> H ❑ <br /> Z <br /> DATE DISCOVERED + HOW DISCOVERED ❑ INV i�yiORR,y,�ONTRQj ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w V uI �u1 p n 1 v ❑ TANK TEST TANNQQKK REMOJJAL GG1l��I ❑ OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> > ❑ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK b REMOVE ❑REPAIR PIPING <br /> O HAS DISCHARGE BEEN STOPPED? k ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE . <br /> o ❑ YES ❑ NO IF YES,DATE uI ul p 11 r REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE f� CAUSE(S) <br /> LLI <br /> a ❑ TANK LEAK UNKNOWN ❑ OVERFILL EDRUPTURElFAILURE ❑:SPILL <br /> N U 0 PIPING LEAK 0 OTHER I] CORROSION ❑ UNKNOWN ❑ OTHER S0 <br /> Lu w CHECK ONE ONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY'',BEEN AFFECTEDI <br /> CHECK ONE ONLY <br /> LL, <br /> ❑ NO ACTION TAKEN F-1PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION, <br /> � <br /> N F7 LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY l <br /> CHECK APPROPRIATE ACTION(S) 0 EXCAVATE L DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) 0 ENHANCED BIO DEGRADATION(IT) <br /> (SEE BACK Fon pETA" <br /> a z ❑O CAP SITE(CO) ❑ EXCAVATE 8 TREAT(ET)' ❑ PUMP&TREAT GROUNDWATER(Gl)❑ REPLACE SUPPLY IRS) <br /> w 1 <br /> c ❑ CONTAINMENT BARRIER(CB} ❑ NO ACTION'REOUTAED(NA] ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> uj ❑ VACUUM EXTRACT(VE) ❑ OTHER(07) <br /> GD !V A^ r/�/�Zl1H' t'1^o � /— !/��� O <br /> z OF 35-0 94 + rso l J rte d- �► o rJ 8-�-9 Fv,,��-�•e� s, <br /> 0 Q'i SS 55 rv��.. W r LL' D. LA I IQ ed <br />