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-- - UNDERGROUND-STORAGE TANK-UN-AUTHORIZED RELEASE(LEAK)-/CONTA 1 <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICESa FOR LOCAL AGENCY USE ONLY <br /> El YES NO REPORT BEEN FILED 7 ❑ YES ❑ NO iHEREBYCERTIFYTHATI HAVE DISTRIB(iTEDTHI OR DINGT E <br /> ,DISTRIBUT(CN SHOWNONTHE INSTRUCTION SHEET.ON THE BACK PAGE OFTHIS FORM <br /> REPORT DATE CASE s <br /> 0 MI 3 MI O d d A q YiY <sIGNED. DATE. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> } arm. ' L. �vn�ef' (5to ) g�t�-941.5 1 <br /> Lu REPRESENTING �OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> 2 ❑ LOCAL AGENCY ❑ OTHER C rQn Pr p v G rn ea n <br /> 2 [ADDRESS .O TJ C2 0 x (00 <br /> D 4 s a <br /> In P-0mon� CA 9'15$3-0904 <br /> STREET CRY STATE ZIP <br /> J NAME CONTACT PERSON PHONE <br /> z. <br /> C�tvron pfoaVC}S cl ❑ UNKNOWN 76rtA L• 1}jJl1}tr i ((510) Sy;_' 9 <br /> U)a ADDRESS Ql{5$3 -QaD4 <br /> P•0• Box (dDy San RAmon) Cly <br /> STREET CRY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> C \tvron sefvit 5 � vv\ c�-am y 0 C�evr'Ort P�oavc.}5 C.o. ( 510) gm-1-905 <br /> LD UADDRESS <br /> o `-1'400 1r`IAjtrloo ►load S�ocmon Sqn joggvin CA5; D5 <br /> Lu STREET CRY COUNTY 21P <br /> H CROSS STREET <br /> N wy q9 <br /> Z LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> ca <br /> z LuSan �loa vrn �o�rt� 1'F}5 IE*D Mtcvtatl lhf vrnol ` (adQ) y106-3454 <br /> W REGIONAL BOARD PHONE <br /> CL <br /> Cc��r'�I Vnllty Rtnlac8 Et��atot}h -T�+pyt� ( (quo ) 255.3133 <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> Lu <br /> wQ <br /> V t\It o►de sol ne_ NKNOWN <br /> m o (2) <br /> yz vstd opt <br /> UNKNOWN <br /> z DATE DISCO VEREDHOW DISCOVERED f7INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w 0.1 .3 MI rL oI Y ❑ TANK TESTTg�Z TANK REMOVAL ❑ OTHER <br /> ¢m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> g <br /> UNKNOWN ❑REMOVE CONTENTS CLOSE TANK b REMOVE ❑REPAIR PIPING <br /> LU M D Y <br /> l yl I <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK S FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> o YES ❑ NO IF YES,DATE p MI 3 j ol 2j q <br /> Y Y ❑REPLACE TANK ❑OTHER <br /> LU SOURCE OF OISC14ARGE CAUSE(S) <br /> crj ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> U ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ?!52NKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY /_" <br /> N p, <br /> U ❑ 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 CHARACTERRATION <br /> Xy ❑ LEAK BEING CONFIRMED F7 PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTIONS) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J 1JM SACK FCR PETALS) <br /> z <br /> ❑ <br /> 00 CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMPS TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w¢ ❑ CONTAINMENT BARRIER(CB) F7NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(0-n 1� 1 <br /> ca <br /> Ltl" ltd soil ov�rc'xcav,%+laA +0 6e- PtctorMtA 04.turding +-o approved <br /> Uj <br /> corrf4lvt Rcvtor ?Ian <br /> 8 <br /> Nsc os tar9rn <br />