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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? QR LOCAL`AGENCY'USE ONLY <br /> ❑ YES NO <br /> ❑ YES NO 1HEREBY CERTIFYTHATi HAVE DISTRIBUTED THISINFbRMATIONACCO(iDINGTOTHE <br /> REPORT DATE DISTRIBLIMN SHOWN ON THE IN N 5HEE7ON THE BACK PAGE OFTHS FORM <br /> F <br /> �M ✓MI Y <br /> SIGNED <br /> NAME OF INDIVIDUAL FILING REPORT DATE <br /> fly PHONE SIGNATURE <br /> m <br /> -4341+1 -LLLI <br /> REPAESENTING ❑ OWNER�OP ATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME r <br /> 2 LOCAL AGENCY ❑ OTHERi`� <br /> ¢ A bRESS C , - 0(rb41 mei <br /> STREETI <br /> w NAME crrr STATE ZIP <br /> CONTACTPERSON PHONE <br /> �� ` <br /> CtJ Y d 56� <br /> oz ❑ UNKNOWN ( /� <br /> ADDRESS �1� TZ" L6S� <br /> Lu O R <br /> IT <br /> CITY <br /> FAC)LITY NAME(IF APPLICABLE) STATE P <br /> OPERATOR PHONE <br /> g <br /> a ADDRESS4 D ©w Ef <br /> N CROSS STREET C CITY couHrY ZIP <br /> ,,, �4 cJ� I 2,,f� <br /> c7 LOCAL AGENCY AGENCY NAME <br /> z_ CONTACTPERSON PHONE <br /> Lu <br /> w w REGIONAL BOARD <br /> /PHONE ` <br /> m (1) 1 NAME L J <br /> 0 w QUANTITY LOST(GALLONS) <br /> p UNKNOWN <br /> j z (z) <br /> w <br /> ❑ UNKNOWN <br /> w DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE ONDITIONS <br /> 7 OM `MI L n� o� �y r ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER {��/�,U {r-o A <br /> aDATE DkSCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M Di b rII UNKNOWN ❑REMOVE CONTENTSCLOSE TANK&REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDUREf(}� <br /> y YES ❑ NO IF YES,DATE E]REPLACE TANK f7 OTHER l� <br /> Q M ARI D D Y Y V <br /> OURCE OF DISCHARGE CAUSES► t <br /> ¢a ❑ TANK LEAK UNKNOWN E] OVERFILL E::] RUPTURElFA1LURE E::] SPILL <br /> m O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> tu a CHECK ONE ONLY <br /> D ❑ UNDETERMINED ❑ SOIL ONLY 4 GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wE-1NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED E:] POLLUTION CHARACTERIZATION <br /> 2 <br /> ❑ LEAK BEING CDNFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POSTCLEANUP MONITORING IN PROGRESS <br /> U ❑ y ❑ CASE CLOSED CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> REMEDIATION PLAN I <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) F-1REMOVE FREE PRODUCT(FP) [—] ENHANCED BID DEGRADATION(IT) <br /> J =SEE Bl1CK FCn dfTA1151 <br /> Fn p ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP 41.TREAT GROUNDWATER(GT)E::] REPLACE SUPPLY(RS) <br /> ~ ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REOUiRED(NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS' <br /> �a ❑ <br /> VACUUM EXTRACT(VE) OTHER(OT) I a �� �e4--rrLI r\P, <br /> U <br /> HSC 05)9901 <br />