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-U <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> EZREPORT BEEN FILED? I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> YES <br /> NO YES ❑ NO DISTRIBU SHOWN ON THE WS TDNSHEET ON THE BACK PAGE OF THIS FORM <br /> RT DATE CASE <br /> Qq/ <br /> PJ / M O Q�v / DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNA - <br /> m <br /> w REPRESENTING REGIONAL BOARD COMPANY OR AGE E <br /> r ❑ OWNERIOPERATOR ❑ <br /> ¢ OCAL AGENCY ❑ OTHER <br /> S <br /> a <br /> AWRESS 1 <br /> 30 <br /> sTsaEer C" BATE zIP <br /> w NAME ^ CONTACT PERSON PHONE <br /> Z� �z�`fyS�N ❑ UNKNOWN <br /> oa <br /> n n ADDRESS <br /> ✓E_FAZIZD w - Lod-rgAve- <br /> FACILITY NAME <br /> CILITYNAME(IF APPLICABLE) OPERATOR PHONE <br /> a ADDRESS <br /> s <br /> Zoos. �J�o Gov_ s4 <br /> w 9TPEET CRY COUNTY 21P <br /> J �c;pAlrc, <br /> EET <br /> J <br /> Z LOCALAGENCY l AGENCY NAME CONTACT PERSON PHONE <br /> wwsa'. ev . lah)S-SVD ( ) <br /> REGIONAL BOARD PHONE <br /> m (L) NAME OUANTITY LOST(GALLONS) <br /> V G' UNKNOWN <br /> a P G <br /> �� m <br /> m ❑ UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL E:] SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> wm C7j 07MI 07 o r Y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> UNKNOWN ❑REMOVE CONTENTS CLOSE TANK d REMOVE ❑REPAIR PIPING <br /> > M O Y Y <br /> 8 HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK CLOSE TANK d FILL IN PUCE ❑CHANGE PROCEDURE <br /> a ❑ YES � NO IF VES.DATE MI D Y Y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSEIS) <br /> ¢j F-1 TANKLEAK UNKNOWN ❑ OVERFILL ❑ flUPTUREIFAILURE ❑ SPILL <br /> a <br /> m U F_� PIPING LEAK OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> ww CHECK ONE ONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHE KONE ONLY <br /> wZ NO ACTION TAKEN ❑ PRELIM(NARY SITE ASSESSM ENT WO RKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> jN LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> ISH MCIITO11onum <br /> 0 <br /> Q ❑ CAP SITE(m) ❑ EXCAVATE d TREAT(EI) ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY IRS) <br /> 00 <br /> w� <br /> wa ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(Vs) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> 9*'� �? A�`— <br /> f <br /> /t�1 ��0'ctxrF ar' C r���AI'�/ <br /> 0 <br /> 0 <br /> HSC o(Mq <br />