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O <br />UNDERGROUND STORAGE TANK UNAUTI-IORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGO4CY SER,. 3/ <br />I I yEs ..3- REPORT SEEN FLED? <br />YE3 1.1.- NO <br />FOR LOCAL AGENCY USE ONLY <br />I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE ANC THAT I HAVE <br />RERTE <br />THIS INFCRMADON TO LOCAL OFFCIALS PURSUANT TO SECTION 25180.7 OF <br />THE H TH AND 4 " 0 <br />..40 <br />, rz_lcilit--) <br />REPORT DATE <br />LI Zli od <br />CASE s <br />SIGNED <br />co <br />NAME OF INDIVIDUAL FILING REPORT PHONE SIGN RE <br />/ <br />o La r- cc 2. <br />REPRESENTING I OWNER/OPERATOR I I REGIONAL BOARD <br />, <br />, COMPANY OR AGENCY NAME <br />-;b1(- /7-,71 ALA c(75(fiffaC-2-14-1 <br />/ <br />CITY STATE ZIP 4 (7t r Al Jo u i <br />I ---LOCAL AGENCY I I OTHER <br />cc ADDRESS <br />STREET i <br />w <br />co <br />NAME <br />i A . . <br />e-O° (._,,t-t-L4 F"--, ,, 4 C.:-,7) ole Pi (12=6:_1175INKNOWN <br />CONTACT PERSON <br />.i.) :y_„0.,..> 7 A j 21-74-1._&.---e- <br />PHONE <br />(:2e1--VK--S---(.5-) <br />9s <br />ZIP <br />0 '-:,- ._ 0. co LL, cC <br />ADDRESS <br />/3q-)(_). (A//9-374//tic7-7.-n,c) f7-3- 97.--r....,J CO- <br />STREET / cm STATE <br />z 0 <br />FACIllITY NAME (IF APPLICABLE) , <br />/-) <br />t <br />OPERATOR 7-1 PHONE <br />n< <br />5 <br />(75 <br />ADDRESS <br />/5 471 --) 0 Wit-IS/EU/U. /6 <br />9n, <br /> <br />i <br /> <br />CITY COUNTY <br /> <br />BR <br />CROSS STREET <br />(0 <br />E CI z <br />ill w <br />a <br />LOCAL AGENCY AGENCY NAME <br />T PSIC-ki) <br />CONTACT PERSON PHONE <br />( 'C?) 9'Ye'":3<(26 <br />PHONE <br />( ) <br />REGIONAL (SCAM <br />C Rc'')Q aa SUBSTANCES INVOLVED NAME QUANTITY LOST (GALLONS) <br />-5eL_ '51156-1- Co Ai S -777-1,y%)u-7-5 <br />/ <br /> <br />I UNKNOWN I COMMENTS I REMEDIAL CURRENT I CASE SOURCE/ I DISCOVERY/ABATEMENT I ACTIC)N STATUS TYPE CAUSE DATE DISCOVERED <br />/1AI .--7L4I Clot -O-.1 /r1 Oil <br />HOW DISCOVERED <br />7 TANK TEST 1.---I <br /> _I INVENTORY CONTROL I 1 SUBSURFACE MONITORING I NUISANCE CONDITIONS <br />REMOVAL I I 011-4ER TANK <br />DATE DISCHARGE BEGAN <br />ml ml DI 01 T1 Y1 <br />EI--CIFA1OWN <br />METHOD USED TO STOP <br />74---116-AOVE CONTENTS <br />DISCHARGE (CHECK ALL THAT APPLY) <br /> <br />I I REPLACE TANK <br /> <br />I, I REPAIR PIPING <br /> <br />d 7711 -4i--k------ <br />[ 1 CLOSE TANK <br />I CHANGE PROCEDURE HAS DISCHARGE SEEN STOPPED ? <br />ZY---ES I I NO IF YES. DATE i ml / hi[ ,00; Z 01 62,„, 0„ <br />7 REPAIR TANK <br />ii---0THg.,,,e,", <br />SOURCE OF DISCHARGE - <br />I TANK LEAK 74--GNI-CNOWN <br />PIPING LEAK I I OTHER <br />CAUSE (S) <br />I 1 OVERFILL 7 RUPTURE/FAILURE I <br />1 I CORROSION H--1:13I1LKOWN <br />I SPILL <br />1 OTHER <br />CHECK ONE ONLY <br />I I UNDETERMINED 2-1---SIC-T-IL ONLY I 1 GROUNDWATER DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />I I NO ACTION TAKEN I I PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED 7 POLLUTION CHARACTERIZATION <br />I I LEAK BEING CONFIRMED I I PRELIMINARY SITE ASSESSMENT UNDERWAY I I POST CLEANUP MONITORING IN PROGRESS <br />I I REMEDIATION PLAN 1 CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTION(S) I I EXCAVATE & <br />(EIEE BACK F030E-TM-SI <br />i I I CAP SITE (CD) I I EXCAVATE & <br />I I CONTAINMENT BARRIER (CB) I I NO ACTION <br />I I VACUUM EXTRACT (VE) 1 I OTHER (0T) <br />DISPOSE (ED) I REMOVE FREE PRODUCT (FP) I I ENHANCED BIO DEGRADATION (IT) <br />TREAT (El) I l',UMP & TREAT GROUNDWATER (GT) I REPLACE SUPPLY (RS) <br />REQUIRED (NA) I 1 TREATMENT AT HOOKUP (HU) I I VENT SOIL (VS) <br />7.4c7z 9 7-•• --3-5/44 elir- <br /> <br />sr Q1i- e•--)c 7-&---707- <br />73 71i — fterg"a P--( (9-ra— >e <br />L-4--- aC"--- - <br />2or-7T7-r4 tiuv9-7-70g-) <br />---&-----ui_r9--inev <br />1Ji --z) <br />a <br />---62 U 1 g&77-7 -7--&----e,-4 /A-) e-- <br />( /LS ,z2 (/ (2 ¼1 <br />(9-c...,-----x.i r , <br />HEIC 05 III /MI