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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY S VICES FOR LOCAUAGENCY US'_ONLY <br /> REPORT BEEN FILED? :.I HEREBY CERTIFYTHAT II HAVE DIST R1130 THIS INFORMATION ACCORDING TO THF <br /> ❑ YES NO ❑ YES NO <br /> DiS IBUTION SHOWN ON THE(NS UC71ON SHEET ON THE BACK PAGE OF.THIS FORM <br /> REPORT <br /> DATE :,� CASES <br /> D uI L/u� O v S HEU Q !DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGTqADAE I <br /> } ctv,4 2G� S (?o`t) ff 33� J1�1`�hQ <br /> REPR ENTING ❑ COMPANY DR AGENCY NAME C <br /> F ❑ OWNER/O ERATOR REGIONAL l� r <br /> ¢ LOCAL AGENCY ❑ OTHERfu �y _ L <br /> s AD RESS �lSZd <br /> n Do s G <br /> 4 V, ��sTael <br /> cm �� srnT� zip <br /> NAME CONTACT PERSON PHONE <br /> J n � <br /> _¢ L✓ r � ❑ UNKNOWN } <br /> aCL <br /> 4 ADDRESS <br /> to <br /> Lu V 11`� ' rae�r ` <br /> CITY 4f, Vic STATE ip <br /> FACILITY NAME(IF APPLICABLE) <br /> ( 6PERA70R PHONE .� <br /> ¢ A009ESLl gD S f[ �/� �/ f r Ad <br /> 4J ►r V' sTseEk�. w L 4-cCITY <br /> G "coiTia� v� zip <br /> CROSS STREET <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON ;I PHONE <br /> zN <br /> wM45 /el-hD <br /> L) <br /> w w REGK)NAL BOAJkOp <br /> HONE <br /> y (I) NAME QUANTITY LOST(GALLONS) <br /> _ UNKNOWN <br /> cn 0 IZ) <br /> mz <br /> U)- .� ❑ UNKNOWN <br /> w DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MOWTORING ❑ NUISANCE CONMTiONS <br /> z <br /> w Qi 1510-17o� r r ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> a <br /> d DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> ❑REMOVE CONTENTS CLOSE TANK&REMOVE.� ❑REPAIR PIPING <br /> s UNKNOWN <br /> w u o o r r ��K111 <br /> n HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK d FILL IN PLACE ❑CHANGE PROCEDURE <br /> oYES NO IF YES.DATE /```J I (}`1j REPLACE TANK OTHER <br /> O Pu 5.1 V D�0 -Y Y a O <br /> SOURCE OF DISCHARGE CAUS (S) <br /> a ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURElFAILURE ❑ir SPILL <br /> y o ❑ PIPING LEAK ��-❑--j OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> N a CHEC NE ONLY <br /> v UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION C4 tARAC7ER17J4710N <br /> Q <br /> ¢ ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U N ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> REMEDIATION PLAN F-1 <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE$.DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> 1WEBNDK r DETAaS) <br /> a z ❑ CAP SITE(CDJ ❑ EXCAVATE 8 TREAT(El) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ❑o <br /> uw�- <br /> Mc F-1CONTAINMENTBARRIER(CB) El NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) E:] VENT SOIL(VS) <br /> LU ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> z <br /> GIiYi� e�G� Int' of Con4cinitn�*r ) <br /> ksC 051&1 <br />