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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES '.FORLOCALAGENCYUSE.ONLY <br /> .' <br /> ❑ YES NO REPORT BEEN FILED 7 ❑ YES ❑ NO 1 HEREBY CERTIFYTHATI HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> REPORT OATS DISTRIBUTION SHOWN ON THE WSTRUCTON SHEET ON THE BACK PAGE OF THIS FORM <br /> (^ NE <br /> CASE, <br /> oM "M SIGNED DATE <br /> NAME OF INDIPHONE SIGNATURE <br /> Y�1arort 0 1 )4toB-3y `I <br /> w REPRESENT" COMPANY OIC AGENCY NAME 'jOPERATOR ❑ REGIONAL BOARD San x,00.�i�.l 1LOCAL O <br /> ADP-1,RES I r VISA QYT <br /> 30q E 3rA F(oor S+ocr_4D,r-\ Rs;;Id <br /> MREET CRY STATE ZV <br /> j NAME' IIrrll CC �f` n CITY <br /> P14ONE ce p <br /> m W AS S 4-r M m^ T"vuvt l P/lr�N OWN alb �Q,$se-,r+nan ( 1 4�— l I f I <br /> w g ADDRESS I 3 � I e. Sc,, <br /> 9s�s <br /> STREET DRY BTATE p <br /> FACILITY NAME(IF APPLICABLE) Y� OPERATOR PHONE <br /> U10.ss.er �YY.1( �\ <br /> JADDRESS U T Y ` g I 47V, �-�V t.,}�E� C�f�TO>"� �P�'\boa n gsae <br /> J V <br /> F CRYNry <br /> w CROSS STREET <br /> ° LOCALAGENCY AGENCY NAME CONTACT PERSON <br /> ww <br /> FPHON�E <br /> 2w sDa .ru �V(ror\ rYa8-3yUw REGIONLBOARD PHD <br /> a � a , L <br /> w (�) NAME QUANTITY LOST(GALLONS) <br /> o <br /> a> g 5 a I I n�- ❑ UNKNOWN <br /> R,> <br /> y <br /> ❑ UNKNOWN <br /> [�2 <br /> GATE DISCOVERED NOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING 4 NUISANCE CONDITIONS <br /> UP <br /> �[Tn `L �T( TANK TEST TANK REMOVAL OTHER <br /> 0 M M t v o 1 1 Y ❑ ❑ 1 <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M DY Y UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK 6 REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED T ❑REPAIR TANK CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> YES ❑ NO IF YES.DATE M D Y Y ❑REPLACE TANK ❑OTHER <br /> D� SOURCE OF DISCHARGE CAUSE(S) <br /> ja ❑ TANK LEAK UNKNOWN ❑ OVERFILL E] RUPTUREIFAILURE ❑ SPILL <br /> �° ❑ PIPING LEAK ❑ OTHER ❑ CORROSION NKNOWN ❑ OTHER <br /> ww C14ECKONEONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> HECKONEONLY <br /> ❑ NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> jH ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ° ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATES DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> Isff e.c.ranonnul <br /> w ❑ CAP SITE(CD) ❑ EXCAVATE d TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTON REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> M <br /> r <br /> 2 <br /> W <br /> 1 <br /> HSC 0IB'9'A <br />