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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCYFUS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY ATION ACCORDING TO THE <br /> ^. . ' C <br /> ❑ REPORT BEEN FILED? YES ED NO I HEREBY CERTIFYTHATI AVE DISTRIBUTED THIS INFORM <br /> YES VDIIS1, ION SH WN ON HEWS tQC O EET ON THE BACKP GE FTTHISF MREPORT DATE CASE8 DATE <br /> r PHONE SIGNAT E <br /> NAME OF INDIVIDUAL FILING REPORT <br /> r GI2 Ohl ( 33 <br /> m CO PANV OR AGENCY NAME <br /> w REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD <br /> LOCALAGENCY ❑ OTHER <br /> i� <br /> ADDRESS <br /> LJ <br /> � � clTr srATE n <br /> NAME <br /> CONTACT PERSONiEf ; PHONE n <br /> j F <br /> m ❑UNKNOWN <br /> H <br /> a <br /> a u ADDRESS <br /> wSTREE cm STATE ZIP <br /> F CILIIV NAME(If APPLICABLE) Or l, PHONE <br /> cI 43L—JbSo <br /> 0 <br /> ADORES T <br /> � STHEf! cm <br /> ccuyry S 3 ZIP <br /> W <br /> �= CROSS STREET <br /> N c <br /> 7 <br /> O LOCALAGENCY AGENCY NAME CONTACT PERSON ��� PHONE <br /> O <br /> zw <br /> w PHONE <br /> w w <br /> REGIONAL BOARD <br /> as ( I <br /> f <br /> NAME QUANTITY LOST(GALLONS) <br /> m (I) 1NKNOWN <br /> w0 � <br /> i <br /> a <br /> i m ❑ UNKNOWN <br /> N <br /> �- DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> i ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN r r METHOD USED TO STOP D���IISCCyy/HH}}}ARGE(CHECK ALL THAT APPLY) <br /> a_ ❑REMOVE CONTENTS�CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> 9¢ y o v ® UNKNOWN <br /> HAS DISCHARGE BEEN STOPPED F-1 REPAIR TANK ❑CLOSE TANK&FILL IN PUCE ❑CHANGE PROCEDURE <br /> 'A YES ❑ NO IF YES,DATE ' A Z U r V ❑REPLACE TANK ❑OTHER <br /> O <br /> SOURCE OF DISCHARGE I�- CAUSE(S) <br /> aj ❑ TANK LEAK IJ�1 UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> O E] PIPING LEAK T❑- OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> ww CHECKONEONLY <br /> U ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIUTION <br /> wZ ❑ NO ACTION TAKEN <br /> ¢r PRELIMINARY SITE ASSESSMENT UNDERWAY <br /> E] POST CLEANUP MONITORING IN PROGRESS <br /> ED LEAK BEING CONFIRMED ❑ <br /> U m ❑ CASE CLOSED(CLEANUP COMPLETED OR UN NECESSARY) ❑ CLEANUP UNDERWAY <br /> REMEDUTION PLAN ❑ <br /> CHECK APPROPRIATE ACTIONO S) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) <br /> E] ENHANCED BIO DEGRADATION(m <br /> Isf.ru raAOE+..m PUMPB TREAT GROUNDWATER(GT) <br /> REPLACE SUPPLY IRS) <br /> a Z El CAP SITE(CD) F-1EXCAVATE&TREAT(ET) ❑ <br /> wa ❑ <br /> NO ACTION REQUIRED(NA) E] TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> CONTAINMENT BARRIER ICE) E:] <br /> ¢ ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> „ S.-F£ AS4ELS <br /> 1J¢[�SSa¢•g ��E <br /> cA3 C,o K•1 aou�+b� <br />