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f <br /> UNDERG OUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SER CES fQR. >'AGENCY-!)SE:ONL ;. <br /> REPORT BEEN FILED i <br /> ❑ YESVINO ❑ YES NO _t HE C fYTFIATi qAV5 ROU. 7HI :ORMATIONA000RDIf�GTOTHE. <br /> fO 18U ON U THESACO(P F <br /> R RT DATE CASEs- <br /> L D ATE <br /> OF INDIVIDUAL FJLINGOF}T� PHONE <br /> (f, i/^fr � iGN R <br /> m <br /> V c �O <br /> w REPRE NTING ❑ OWNERJOPERATOR ❑ REGIONALBOARO COMPA q ENCYNAE � <br /> LOCALAGENCY ❑ OTHER <br /> ¢ ADD- f �✓ ! - ( J6STREET q�� V V C � stAr� - zip <br /> wMt CON ACT PERSON } - PHONE <br /> C�rZ rR �Kl"3y) [:J UNKNOWN �r-v 1 '+`-> 9 <br /> a <br /> a qRESS <br /> f <br /> a Z /V . T Y l�- STATE (� V <br /> CILfY NAME(IF PLICABLE) OP/ TOR r rPHONE i <br /> p57- <br /> � [ l <br /> O AD SS 00,Yll 7� r rlas s -s+dxb , <br /> w <br /> m CR <br /> 0, <br /> T/6 A AGENCY NAME CONTACT PERSON PHONE <br /> Y <br /> UJ I <br /> �w Rt BOARD� n .- PHONE - <br /> y (t) NAME QUANTITY LOST(GALLO ) <br /> zw UNKNOWN <br /> Q J <br /> -ik" <br /> H <br /> mz (2) <br /> ' ❑ UNKNOWN <br /> DATE DE VERSO HOW DISCOVERED r7NVENTORY CONTROL ❑ SUBSURFACE MONiTORI G ❑ �N/UISAN E CbNDMONS <br /> ©u1 I V r�o y y ❑ TANK TANK REMOVAL OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCH GE(CHECK ALL THAT APPLY).r <br /> u o UNKNOWN ❑REMOVE CONT7=NTS CLOSE TANK a REMOVE ❑REPAIR PIPING <br /> o HAS D RGE BEEN STOPPED i ❑REPAIR TANK ED CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> InYES ❑ NO IF YES.DATE y y ❑REPLACE TANK ❑OTHER ' <br /> SOURCE OF DISCHARGE USES) <br /> v F7 KNOWN LEAK UNKNOWN ❑ OVERFILL ❑ UPTURE/FAILURE ❑ SPILL �I <br /> w ❑ PIPING LEAK ❑ OTHER ❑ CORROSION KNOWN ❑ OTHER <br /> ww CHE NE ONLY <br /> 5 CL <br /> cai UNDETERMINED ❑ SO1L ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTEO EDPOLLUTION CHARACTERIZATION <br /> Lu <br /> jy ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE A DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> 1>M NAM ran WtALP <br /> C3 O ❑ CAP SrTE(CD) ❑ EXCAVATE 5 TREAT(ET) ❑ PUMP 3 TREAT GROUNDWATER(GT)E:] REPLACE SUPPLY(RS) <br /> w< <br /> CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> cr <br /> ❑ VACUUM EXTRACT(VE) Oz4X❑o�O}THER(OT) ��/u <br /> W 7V <br /> 49-1 <br /> ul <br /> �� 4 <br />