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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />REPORT BEEN FILED ? <br />FOR LOCAL AGENCY USE ONLY <br />r7 YES NO YES NO <br />❑ <br />1 HEREBY CERTIFYTHAT.1 HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br />DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. a` <br />REPORT DATE' <br />CASE x <br />SIGNED DATE <br />Y <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE <br />} <br />m <br />Z <br />6 Lr <br />REPRESENTING ❑ OWNER/OPE AOR ❑ REGIONAL BOARD <br />E::] OTHER <br />COMPANY OR AGENCY NAME <br />D <br />p'LOCAL <br />AGENCY <br />ADDRESS <br />STREET CITY STATE ZIP <br />co <br />Z� <br />NAME CON PERSON PERSON J /}- 1 <br />a I �.ee Vb' ❑UNKNOWN Yli li,/� I ��/CG� <br />PHONE �( 'j <br />�� / �O I J <br />a as <br />cn <br />ADDRESS <br />STREET CITY STATE ZIP <br />FACILITY NAM (IF APPLICABLE) _ <br />OPERATORy�� 13 u.tl I PHONE <br />Z <br />0 <br />UADD•RzESS <br />�''� �Q .{� r' f� n• _j__ ��� L� <br />w <br />STREET CITY COUNTY ZIP <br />~ <br />CROSS STREET <br />E l 2� <br />0 <br />Z <br />LOCAL AGENCYJ AGENCY NAME CONTACT PERSON <br />S.. Cc ?�i �' - 1-{_ <br />PHONE <br />w <br />REGIONAL BOARD <br />PHONE <br />(1) NAME QUANTITY LOST (GALLONS) <br />LU p <br />Z <br />a J <br />UNKNOWN <br />co <br />w Z <br />(2) F 9UNKNOWN <br />z <br />Lmz <br />DATE DISCOVERED <br />0111 <br />HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING F7 NUISANCE CONDITIONS <br />H <br />C I I <br />M MD V Y <br />I I L <br />❑ TANK TEST n TANK REMOVAL OTHER�jj <br />m <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />a <br />MI M of o r r UNKNOWN <br />REMOVE CONTENTS CLOSE TANK & REMOVE ❑ REPAIR PIPING <br />Lu <br />0 <br />Uj� <br />❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PACE ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED ? <br />7 <br />YES ❑ NO IF YES, DATE 3 V <br />❑ REPLACE TANK ❑ OTHER <br />MI MI DI DI Y Y <br />,-a <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />ja <br />}�,I <br />F7TANK LEAK I JQ UNKNOWN <br />F7 OVERFILL F7RUPTUREIFAILURE ❑ SPILL <br />V) O <br />I F7 PIPING LEAK F7OTHER71CORROSION <br />UNKNOWN F7OTHER <br />w w <br />wa <br />CHECK ONE ONLY <br />U �7 <br />❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKINGWATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CH�CKPNE ONLY <br />z <br />w <br />I JQ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />c❑ <br />LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />U <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTION(S) EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />(SEE BACK FCR DETA") <br />a z❑ <br />CAP SITE (CD) EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />w 0 <br />❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) VENT SOIL (VS) <br />cc:❑ <br />VACUUMEXTRACT (VE) ❑ OTHER (OT) <br />cn <br />Z <br />C� <br />L) <br />HSC 05 (490) <br />r/ <br />