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4k 4 UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES REPORT BEEN FILED 7D F-1 �NO �O FOR LOCAL AGENCY USE ONLY M. 1 HERESY CE.YTHAT i HAVE; DIST RIB UTE THIS INFORMAT10N ACCORDING TO THE YES ❑ YES pISTRIBUTKIII SHOWN ON THE wURUCTION SHEET ON THE BACK PAGE OF THIS FORM 3 R�EyPORTyDATE CASES Z % t M f• M J 'C% ! Y $ICaNED DATE :. NAM OF INDIVIDUAL FILING REPORT PHONE �3 SIG R >- e�x1 R C� C. i (�lcJ) C C� `ii.7 —• l �.: w REPRESENTING OWNER/OP TOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME g ❑ LOCAL AGENCYOTHER cr ADDRESS / ® C Cm 4-d'I nN STATE zip Lu NAME )S CONTACT P/ERSO/N� PHONE 6 �� i CA k A C a UNKNOWN 10 j (2' /63 z� Wi G��l l (��6j C l) ti a ¢ ADDRESS' P.i& S f&-- �C cri- 1 x STREET CITY STATE IP FACILITY NAME (IF APPLICABLE) OPERATOR 7 PHONE Gkev r on - �� d ? r�� 5 �.4 ��s�) - `�i3 Z zl3 o ADDRESS "^ " `' " "� S -S Lu STREET ," y cm a �� courrry ZIP t= CROSS STREET O LOCAL AGENCY AGENCY NAME CONTACT PERSON �K.I PHONE wU Gj ivs L C w w REG NAL BOARD PHONE y LU 0 (1) NAME QUANTITY LOST (GALLONS) J J - UNKNOWN m (Z) �z y ❑ UNKNOWN Z (DATE DISCOVERED C C' �M HOW DISCOVERED � INVENTORY CONTROL ❑ SUBSURFACE MONITORING `❑ NUISAN7C�E CONDITIONS ❑ TANK TEST ❑ TANK REMOVAL OTHER /(µN/i� S �/ M) o� DI r 1 Y //i 5 e'er m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) a cc IUNKNOWN M M D D Y r REMOVE CONTENTS CLOSE TANK &REMOVE O REPAIR PIPING Lu p ❑ REPAIR TANK ❑ CLO TANK &%FILL IN PLACE 4 CHANGE ROCEDURE HAS DISCHARGE BEEN STOPPED? o 61 YES ❑ NO IF YES, DATE LM j ❑ REPLACE TANK OTHER / �C' U o r ! Y SOURCE OF DISCHARGE CAUSE(S) ❑ TANK LEAKUNKNOWN F-� OVERFILL TURE/FAILURE ❑ SPILL y O ❑ PIPING LEAK ❑ OTHER �E�:]RU ❑ CORROSION NOWN © OTHER Lu a CHECK ONE ONLY U ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION ;5 ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS U ❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY J CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) (SFE BACK FOR WTALM z wEl SITE (CD) ❑ EXCAVATE & TREAT (ET) E:]PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) — w a F—]CONTAINMENTBARRIER (CB) ❑ ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU)VENT SOIL (VS) ❑ VACUUM EXTRACT (VE) ( OTHER (OT) / iL—� b�� u C (c�%21 G✓ �' z z 61 w 0 O U HSC 05 (SBC)