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6 -(/; <br />(C- <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY _ HAS STATE OFFICE <br />REPORT BEEN <br />I I YES A NO <br />OF EMERGENCY SERVICES <br />FILED? <br />NO <br />FOR LOCAL AGENCY USE ONLY - <br />.. I HEREBY CERTIFY THAT I. HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE , <br />DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM: ., <br />YES <br />x <br />REPORT DATE <br />° MI itul el te 01 q ' 6 Y <br />CASE # <br />SIGNED DATE . <br />m <br />NAME OF INDIVIDUAL FILING REPORT <br />. h e,„_. -6 ri s <br />PHONE SIGNA E <br />(,.;06./)q.t.e-c3ti.- g <br />uo, <br />F- rr <br />0 <br />REPRESENTING Li OWNER/OPERAIR I I REGIONAL BOARD <br />LOCAL AGENCY I I OTHER <br />COMPANY OR AGENCY NAM J _ """" k &In) Jo a °P ,. by 0 PO -74 fill ft" <br />i712 A DRESS <br />30i E 6 ( ).0e./1- / P 0, ige"-A 3W- Si-oce-evu Cí9 KJ 0 I <br />STREET CITY STATE ZIP RESPONSIBLE PARTY NAME <br />6*// 0 ; / d'Clikr a' Li UNKNOWN <br />CONTACT PERSON <br />Eititi i roll i Alai t. <br />PHONE <br />(SW) eol.---6, /Y:‘ <br />ADDRESS <br />/ 3 9 1) td i 1 i ertO ,Tfa,s' al. geuil-e ?00 Ce-yzzisii- 09- 947 46 0 CITY STATE ZIP SITE LOCATION FACILITY NAME (IF APPLICABLE) <br />rja4,110.a, ,_s 'tie& <br />OPERATOR <br />sika 61' I <br />. PHONE <br />(5i 0) 40 -15-- 6100 <br />ADDRESS <br />0.e/1 1' IE. FAII-ndytZ <br />STREET <br />Stec i liVe <br /> <br />_c,J'. g5AO 5 <br /> <br />COUNTY ZIP CITY <br />CROSS STREET <br />Ft' I ber I- IMPLEMENTING AGENCIES LOCAL AGENCY a i iEivijAG,ENHCY..eNAM422±E L b i Li, <br />SAN :le <br />.. CONTACTL0,eteta_d PERSON _ratit4ealte PHONE <br />POI ))14 ,..31/i4 / <br />REGIONAL BOA <br />_('R Oa) c 13 <br />PHONE <br />( ) DISCOVERY/ABATEMENT I SUBSTANCES INVOLVED (1) NAME QUANTITY LOST (GALLONS) <br />UNKNOWN >< <br />(2)Ytg6.64" <br />I I UNKNOWN <br />DATE DISCOVERED . . <br />6 ul If ml ;el DI g DI gYI (e) Y <br />HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br />I <br />I TANK TEST ><[ TANK REMOVAL I I OTHER ; <br />DATE DISCHARGE BEGAN <br />kil ml 01 DI Y1 YI <br />' <br />METHOD USED TO STOP <br />Li REMOVE CONTENTS <br />DISCHARGE (CHECK ALL THAT APPLY) <br />LOSE TANK & REMOVE I I REPAIR PIPING <br />I I CHANGE PROCEDURE <br />I <br />UNKNOWN <br />I I CLOSE TANK & FILL IN PLACE <br />I I OTHER <br />HAS DISCHARGE BEEN STOPPED? . <br />DATE 4,11f mi ,-,1 DI S Di 6/ „I 6 y <br />I I REPAIR TANK <br />I I REPLACE TANK YES I I NO IF YES, I SOURCE/ CAUSE OURCE OF DISCHARGE <br />I I TANK LEAK <br />I I PIPING LEAK <br />UNKNOWN <br />OTHER <br />1 CAUSE(S) <br />I I OVERFILL I I RUPTURE/FAILURE I I SPILL <br />OTHER <br />x. <br />I 1 I I CORROSION K UNKNOWN Li <br />w LB 0 0_ <br />C.) <br />CHECK ONE ONLY <br />I UNDETERMINED SOIL ONLY I I GROUNDWATER I I DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CURRENT 1 STATUS CHECK ONE ONLY <br />I I NO ACTION TAKEN <br />I I LEAH BEING CONFIRMED <br />I REMEDIATION PLAN <br />Li PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED I I POLLUTION CHARACTERIZATION <br />ASSESSMENT UNDERWAY I I POST CLEANUP MONITORING IN PROGRESS <br />COMPLETED OR UNNECESSARY) I I CLEANUP UNDERWAY <br />X. PRELIMINARY SITE <br />I 1 CASE CLOSED (CLEANUP REMEDIAL ACTION CHECK APPROPRIATE ACTION(S) EXCAVATE & ISEE BACK FOR DET ALS) <br />I I CAP SITE (CD) I _ I EXCAVATE & <br />I I CONTAINMENT BARRIER (CB) Li NO ACTION <br />I VACUUM EXTRACT (VE) Li OTHER (OT) <br />DISPOSE (ED) I I REMOVE FREE PRODUCT (FP) I I ENHANCED BIO DEGRADATION (IT) <br />TREAT (ET) I I PUMP & TREAT GROUNDWATER (GT) I I REPLACE SUPPLY (RS) <br />REQUIRED (NA) I I TREATMENT AT HOOKUP (HU) I I VENT SOIL (VS) COMMENTS I 1 <br />1‘34,t4_) k et,,j ,jAa /4-02,0to <br />di/V(4lb-, <br />*, S.,' & b te-4-12 i l if ' fel-- <br />HSC 0618/90)