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UNDERGR ND STORAGE TANK UNAUTHO ZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVES PaElllBYF <br /> ENCYLSE ON <br /> REPORT BEEN FILED? <br /> ❑ YES NO ❑ YES NO IYTHATI AVE STRIBUTEDTHI NFNMATION ACCORDINGTOTHE <br /> OWN TI J U SH ON THE BACK PAGE OFTHIS FORM <br /> RTDATE CASE• DATE <br /> N F INDIVIDUAL FIL REPORT PHONE SIGN qE <br /> m � G�"T )y�8-� 3s <br /> w REPRESE G ❑ OWNEROPERATOR ❑ REGIONAL BOARD COM�/A{�Y�q{-RCAGENCY NAM <br /> OCAL AGENCY ❑ OTHER r // J ' <br /> S AOD ES <br /> S / v " • STATE 9 p <br /> J NAM CONTACT PERSON r <br /> ire ❑ UNKNOWN <br /> a g ADDRESS <br /> 352 mer �t�v l�bv.) /l/lAP } CA STAW 9Nss8 <br /> FACILRY NAME(IF APPLICABLE) /�y/�C OPERATOR PHONE <br /> y <br /> ADDRE SJ.te / ✓v�/P� <br /> O C//•v,(Igy�l�ill� <br /> yCROSSSTREET <br /> AGENCY NAME CONTACT PERSON <br /> 5 PHONE <br /> w <br /> �w RE�pNALBOARDIA' <br /> _` (./ ✓If� YV <br /> 6(18 <br /> (HONE ` <br /> w IA �JNAME QUANTITY LOST(GALL <br /> Ow L <br /> a� � /IL2i UNKN <br /> aO <br /> UNKNOWN <br /> i DATE DISCOVERED NOW DISCOVERED ❑ AVENTORY CONTROL O SUBSURFACE ONITORING O NUISANCE CONDITIONS <br /> OM M ' d u r 2r ❑ TANK TANK REMOVAL ❑ OTHER C� <br /> Q DATE DISCHA GE BE METHOD USED TO STOP DISCHA (CHECK ALL THAT APPLY) <br /> W Y UNKNOWN ❑REMOVE CONTENTS CLOSE TANKi REMOVE E:]PEPAIR PIPING v 1 <br /> HAS DIS RGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK i FILL IN PLACE E:]CHANGE PROCEDURE <br /> O YES ❑ NO IF YES.DATE /n r 2r ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE W CAUSE(S) <br /> ¢j ❑ TANK LEAK JVUNKNOWN ❑ OVERFILL ❑ R RFJFAILURE O SPILL <br /> a <br /> m0 ❑ PIPING LEAK THER ❑ CORROSION UNKNOWN ❑ OTHER <br /> wn CHECK ONE ONLY <br /> ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> wZ ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ❑ 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 i DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> Z 1✓�vcx Twm� <br /> oO <br /> ❑ CAP SITE(CO) ❑ EXCAVATE i TREAT(ET) PUMP i TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY IRS) <br /> r <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> - I_I <br /> W1d�lvt� <br /> 4- <br /> 0 <br /> 0 <br /> HBC oslMw <br />