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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY'USE ONLY REPORT BEEN FILED 7 YES ❑ No ❑ YES ❑ No )HEREBY CERTIFY THAT 1 HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO7HE DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM REPORT DATE Ey5rlf;"&*l/o s M /J�` SIGNED DATE NAMEGN E OF INDIVIDUAL FILING REPORT PHONE SI -�' _ � iso (ire ) V o " w REP ENTING ❑ca OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME ,,_fi.�g)i,/ /��/��/ gLOCAL AGENCY ❑ OTHER 49.0N �V Y IA v f'"1 v l, L b60 cr ADDRE t f � E�3�'r �'/-T `?-?Z 2 �.7JGfV_] STREET w NAME f CONTACT PERSON / PHONE (j co z ! � M A L e-K ❑ UNKNOWN 1 , 1 I h eC..�D��® (Z i) �43 o a ADDRESS ..ACC A VE PAN fC SCA 95733- Lij �� STREET CITY FACILITY NAME(IF APPLICABLE) _ _ OPERATOR PHONE E� 6� 'S �-v �Ael-j AMA L a ADDRESS ' W STREET (OL) v - JV Bap., g S y CROSS STREET �^ MESS f Q� /let IT LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE z Alc01%A (Zell 40 Lu 51,W 1:6AAA&I awkwAIWL w wREGIONAL BOARD PHONE CL < c 1!v p\ vi 9 c ( } m (t) ll, ,^ NAME QUANTITY LOST(GALLONS) LU W , 1�I E /�` Se UNKNOWN a? (2) ti ❑ UNKNOWN z DATE DISCOVERED /��/ HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS w ® M1 3 MI ®DI 8 DI + r y ❑ TANK TEST ° TANK REMOVAL ❑ OTHER `Y f- m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) UNKNOWN ❑REMOVE CONTENTS,❑CLOSE TANK&REMOVE ❑REPAIR PIPING M D Y Y x { I p HAS DISCHARGE BEEN STOPPED 1 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE F7CHANGE PROCEDURE o _tg YES ❑ NO IF YES,DATE M 011 yl y ❑REPLACE TANK ❑ OTHER SOURCE OF DISCHARGE CAUSE(S) ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL y v ❑ PIPING LEAK ❑ OTHER ❑ CORROSION _UNKNOWN F--] OTHER w wa CHECK ONE ONLY �� U 2!�UNDETERMINED ❑ SOIL ONLY E] GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY z ❑ NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION w w j ti ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) aZ tWe SACK FOR MALM F3 o ❑ CAP SITE(CD) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP E TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) La a❑ CONTAINMENT BARRIER(CB) E] NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) E::] VENT SOIL(VS) ❑ VACUUM EXTRACT(VE) OTHER(OT) A-55e5.1; z ADDU OA(A-L x-556&5MCk) a� C®NIS M t NST oN �zvj w 8 HSC 05(8^90)