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• U-+4- <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 1 HEREBY CERTIFY THAT i HAVE DISTRIBUTED THIS INFORMATION ACCORDING-0 THE <br /> YES NO YESNO <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET lI ON THE BACK PAGE OFTHIS FORM. <br /> REPORT DATE CASE III <br /> cr_ 7 -77 <br /> kd C%i `' d 1 Yl 1 SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT I PHONE S <br /> co <br /> w REPRES TING OWNERiOPERATOR a REGIONAL BOARD COMPANY OR AGENCY NAME <br /> ¢ 1 <br /> LOCAL AGENCY OTHER <br /> s ADDRESS <br /> C cm ILIA <br /> rE nv <br /> w N E CONTACT PERSON (� \ < PHONE< <br /> m� � LCf�t=ST�I`. UNKNOWN 1�C+'1 ��'� l (-7 LyG�Vi4I..`�''J� (�LJ) ��j�Z�) <br /> Z <br /> CL ADDRESS 4 <br /> ¢a S 2— <br /> S. —,Er ' S/'�' V 1 O'v l� 1 C� STATE p <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> C <br /> C �� Lp- <br /> a ADDRESS <br /> CTI coufvrY ZIP <br /> CROSS STREET <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w REGIONAL BOARD PHONE <br /> a a / <br /> � 1 ) <br /> w (i) NAME QUANTITY LOST(GALL S) <br /> O <br /> Lu ! \ UNKNOW N <br /> �� C�V L, j C�>�v <br /> m i (2) <br /> U) UNKNOWN <br /> - DALu _TE E} /C HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> w (L� / Y TANK TEST f;K/TANK REMOVAL OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> 0 <br /> a <br /> s µ o UNKNOWN REMOVE CONTENTS LOSE TANK 6 REMOVE REPAIR PIPING <br /> w <br /> o HAS DISCHARGE BEEN STOPPED t REPAIR TANK CLOSE TANK d FILL IN PLACE CHANGE PROCEDURE <br /> o �/ YES = NO IF YES.DATE C.MI j 1 0 vl y REPLACE TANK OTHER <br /> al uj S07 OF DISCHARGE CAUSE(S) <br /> 2 j ,U( TANK LEAK Q UNKNOWN OVERFILL RUPTURE/FAILURE SPILL <br /> CO a PIPING LEAK Q OTHER CORROSION UNKNOWN Q OTHER <br /> y wCHECK ONE ONLY <br /> CL <br /> O UNDETERMINED SOIL ONLY (� GROUNDWATER DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY SEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z c NO ACTION TAKEN a PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED Q POLLUTION CHARACTERIZATION <br /> w <br /> LEAK BEING CONFIRMED a PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> O dREMEDIATION PLAN a CASE LOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK tAPPROPRIATEM -ORM�ACTION(S) EXCAVATE 6 DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> O O Q CAP SITE(CD) EXCAVATE 6 TREAT(ET) �� PUMP b TAEA7 GROUNCWATER(GT)0 REPLACE SUPPLY(RS) <br /> w c CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> cr O VACUUM EXTRACT(VE) a OTHER(OT) <br /> U) <br /> 2 <br /> UA <br /> O <br /> J <br /> fisc 051&907 <br />