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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> VES NO <br /> REPORT BEEN FILED T VES NO I HEREBY CERTIFY THAT I.HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INS TION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORTDATE CASE <br /> � IM.e <br /> M v 'SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT (PHONE SIGNATURE <br /> m <br /> w REPRESENTING OWNEFVOPERATOq O REGIONAL BOARD COMPAN OR AGENCY NAME <br /> ¢ LOCAL AGENCY 0 OTHER <br /> S <br /> a ADDRESS J <br /> SVREIf + -r c" STATE g—A ZIP / <br /> w NAME CONTACTPERSON PHONE <br /> i c UNKNOWNIL 'by v _ D 3 <br /> Oa< ADDRESS <br /> w n �rr tJ <br /> ¢ B y STREET ! 1 CRV STAT£ iv <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> >c � ) <br /> < ADDRESS <br /> Q <br /> O <br /> W 3TRfff � � CfIY CWMY 21P <br /> Fq CROSS STREET <br /> g LOCALA NCV AGENCY NAME CONTACTPERSON PHONE <br /> ry I <br /> WS1 <br /> w flEGK)N BOARD PHON <br /> na / <br /> � t I <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> UO <br /> <j NKNOWN <br /> 23 <br /> (� <br /> N <br /> O UNKNOWN <br /> i DATE DISCOVERED HOWDISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING 0 NUISANCE CONDITIONS <br /> m 64 u 14 .1 v Y ❑ TANK TEST TANK REMOVAL OTHER `+ A <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> ¢ <br /> III DI YJ r <br /> UNKNOWN I]REMOVE CONTENTS Q CLOSE TANK d REMOVE REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED 7 O REPAIR TANK O CLOSE TANK d FILL IN PUKE O CHANGE PROCEDURE <br /> o I] YES E�] jNO IF YES,DATE u DI d Yl Y Q REPLACE TANK O OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> gm <br /> F-� TANK LEAK UNKNOWN OVERFILL 0 RUPTUREIFAILURE Q SPILL <br /> w O F--j PIPING LEAK OTHER CORROSION UNKNOWN Q OTHER <br /> w CHECKONEONLY <br /> F7 UNDETERMINED SOIL ONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> w F-1 NO ACTION TAKEN Q PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED 0 POLLUTION CHARACTERIZATION (� <br /> jy O LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY a POST CLEANUP MONITORING IN PROGRESS <br /> O 0 REMEDIATION PLAN D CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUPUNDERWAY <br /> CHECK APPROPRIATE ACTION(S) O EXCAVATE&DISPOSE(ED) O REMOVE FREE PRODUCT(FP) a ENHANCED BIO DEGRADATION(IT) <br /> 1 srx 77 <br /> CAPF-1CAP SITE(CM O EXCAVATE d TREAT(ET) PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY IRS) <br /> wg <br /> w< CONTAINMENT BARRIER(CS) O NO ACTION REQUIRED INA) O TREATMENT AT HOOKUP(HU) O VENT SOIL NST <br /> VACUUM EXTRACT(VE) 0 OTHER(OT) <br /> w <br /> 0 <br /> O <br /> Q <br /> HSC as�eisol <br />