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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES rFOR LOCAL-AGENCY USE ONLY <br /> VES NO <br /> REPORT BEEN FILED 7 YES „1 HEREBY CERTIFY THAT i HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ ❑ NO <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATECASE b <br /> M M r :.SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIG HE <br /> w REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> g ❑ LOCAL AGENCY [N OTHER v C <br /> ADDRESS <br /> IP <br /> STREET cm STATE <br /> w NAME CONTACT PERSON PHONE <br /> n <br /> UNKNOWN <br /> z (9a <br /> 2 - oa3 <br /> y ADDRESS <br /> V��gREE1 Cm STATE I A ��P� <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o ( ) <br /> < ADDRESS <br /> 33 REE cm COUN r <br /> y <br /> CROSS STREET —IID <br /> O LOCAL AGENCY AGGEENCY NAME CONTACT PERSON PHONE O <br /> Z y W V <br /> w <br /> w REGIONAL BOARD PHONE 1 <br /> a ( ) <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> w0 <br /> w UNKNOWN <br /> a3 <br /> H ❑ UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITO,RING1 ❑ NUISANCE CONDITIONS <br /> uI D r v ❑ TANK TEST ❑ TANK REMOVAL OTHER m <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑REMOVE CONTENTS tC CLOSE TANK b REMOVE ❑REPAIR PIPING <br /> y 4 D Y <br /> l A <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK b FILL IN PLACE ❑CHANGE PROCEDURE <br /> o YES ❑ NO IF VES,DATE M U v �Y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> `j TANK LEAK F-1UNKNOWN ❑ OVERFILL RUPTUREIFALURE ❑ SPILL <br /> h0 ❑ PIPING LEAK ❑ OTHER CORROSION ❑ UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> O ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w� ❑ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTIONCHARACTERIZATION <br /> �y ❑ 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 IATE APPROPRACTION(S) EXCAVATE6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) E] ENHANCED BIO DEGRADATION(IT) <br /> teff APPROPRIATE <br /> a0 F-1 CAP SITE(CO) EXCAVATEb TREAT(ET) PUMP&TREAT GROUNDWATER(G7)❑ REPLACE SUPPLY(RS) <br /> 0059 <br /> wa ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED MA) TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ¢ ❑ VACUUM EXTRACT(VE) - ❑ OTHER(OT) <br /> I,tST o��sco�er� Q�,c�WyeSod�rhsnaQ <br /> HSC Z 1"0) <br />