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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ <br /> VES NO <br /> REPORT BEEN FILED? VES NO I HEREBY CERTTY.THAT HAVE DISTRIBUTED THIS INFORMALION ACCORDINGTOTHE❑ <br /> DISTRIBUTION SHOWN,ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE CARE s <br /> l <br /> 8 u v <br /> SIGNED DATE <br /> NAME OF INDIVIDUAL FILING @0RT l PHONE SIGNATURE <br /> 1I' \/09 <br /> w REPRESENTING ❑ OWNEWOPERATOR ❑ REGIONALBOARD COCMPANY OR AGENCY NAME <br /> ¢ OCAL AGENCY ❑ OTHER TL�DA �V I rD TNRP✓I��LI <br /> E C" <br /> ¢ ADDRESS <br /> boo C— • {/Rla( nC. 9s <br /> STREE! CITY s`ATe ZIP <br /> j NAME .(� <br /> Z¢ � \ C•N. �� E <br /> CONTACT PERSON <br /> fO-L CL+ r "'cyyf❑ UNKNOWN Gh'Ar^Mjk+ - AflA <br /> ) <br /> a< ADDRESS tj <br /> 39 4 b �I "Tr Tz l ��L "► emSTw <br /> �1S3o Y <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> 'bra �r�ck f {��1-r7 cM-, . + �w-Ff c ) <br /> a ADDRESS <br /> 3q �o N , `fr� 431 �� �u S Joa 9ssoy <br /> � � cm Dou nP <br /> y CROSS STREET <br /> Z LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w J0.nJoa IrtGo, End . 1Fe< f�t� yV�on a L r10 (y�) rybd-3 �l(f <br /> w5 <br /> w REGIONAL BOARD PHONE <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> Q <br /> a J I C 5 e ( UNKNOWN <br /> O <br /> ym> RI <br /> y ❑ UNKNOWN <br /> i DAAT�E�DISCOVERED ' /� HOWDISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACEMONITORING E:) NUISANCE CONDITIONS <br /> r uI ✓ D D Y y ❑ TANK TEST ❑ TANK REMOVAL OTHER (6 a.rrq e <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> t <br /> w u D Y Y VX <br /> UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK 6 REMOVE ❑REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK 6 FILL IN PLACE ❑CHANGE PROCEDURE <br /> y <br /> p YES ❑ NO IF YES.DATEM D1 Lld Y Y O 9 ❑REPLACE TANK OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢j ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> a <br /> m0 ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> O 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 E:] POLLUTION CHARACTERIZATION <br /> jm ® LEAK BEING CONFIRMED ❑ PRELIMINARYSITE ASSESSMENT UNDERWAY ❑ POSTCLEANUP MONITORING IN PROGRESS <br /> O ❑ 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 /> Oa�wca ra.oerval <br /> 0 4 ❑ CAP SITE(CO) ❑ EXCAVATE&TREAT(ET) ❑ PUMP i TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> wr <br /> w< ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> Fvur-1KL' 1rt V S4-19 c,-4-(B r\ OT GUA'L—imn-L I OL.A-4LZ l l b <br /> Lo 0 <br /> s <br /> H9D OS IAy% <br />