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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINA I <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 ❑ YES ❑ NO 1 HEREBY CERTIFYTHAT I.HAVE DISTRIBUTED THIERAMI TH� H r� <br /> E] YES ❑ NO DISTRIBUTION SHOWN ON THE INSTRUCTION SHE L <br /> REPORT DATE CASE s <br /> DATE <br /> SIGNED <br /> D M M PHONE y �� SIGNAtU 8Z\ <br /> J� <br /> NAME INDIVI FIL NG REPORT I. / . �^) l Alo <br /> in ^ r <br /> (�1.1 V OC/• • <br /> i' COMPANY OR AGENCY NAM <br /> ❑ r <br /> REPRESENTING OWNER/OPERATOR REGIONAL BOARD / D /. <br /> Lu <br /> ~ (� <br /> ❑ LOCAL AGENC THER 3 <br /> Q ADDRESS ^, (/y r ( / <br /> 4. � / ©" STATE / ZIP <br /> '/ / <br /> Vv/ STRE/'�� (\'"� N^TA/��_ Jto) <br /> ONE <br /> V 017RN CU I "E <br /> Lu NAME rr � -2 <br /> J 0 / l <br /> CD <br /> w P <br /> X19f-�k� <br /> - � 0 ��38 <br /> d a ADDRESS O l <br /> [hJ,�J�/ (//� � ITY� STATE ZIP <br /> Cc <br /> • sT�IEEr ` `�' PHONE <br /> OPERATOR �-. y,` Q n I c) ^^ \ <br /> FACILITY NAME(IF APPLICABLE) L Q �/N,�Q,(� W `w/ 51✓ - ]' <br /> ;gt 02© S v ( <br /> z <br /> a Ld vi gY <br /> /� n <br /> ADDRESS f1 \/?/� Owl 7 GL� r/ <br /> C C Ty ZIP <br /> aoo ITR ET <br /> W <br /> r CROSS STRE T <br /> In <br /> O <br /> PHONE <br /> LO LAGENCY AGENCY NAME <br /> CONTACT PERSON <br /> z O r. <br /> ~w l/�(• Oct U/1 ,19a <br /> PHONE <br /> Z U <br /> w <br /> M w REGIONAL BOA 0 <br /> J <br /> a QUANTITY LOST(GALLONS) <br /> NAME ❑ <br /> (�) �4 • UNKNOWN <br /> w <br /> z> <br /> Q J <br /> m 05 (2) ❑ UNKNOWN <br /> HOW DISCO ❑ ❑ U RFAC� MONITORING NU E CONDITIONS <br /> INVENTORY CONTROL Si <br /> Z DATE DISCOVERED VERED <br /> w MI MI DI OTHER <br /> 43 ❑ TANK TEST TANK REMOVAL <br /> DI Y Y <br /> r <br /> METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> mDATE DISCHARGE BEGAN <br /> a ❑ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE E]REPAIR PIPING <br /> W M M D Y ❑REPAIR TANK ❑CLOSE T FILL PLA E ❑CHANGE PROCEDURE <br /> 0 HAS DISCHA EEN STOPP D 7 <br /> 0 ❑REPLACE TANKOTHER <br /> `n YES NO IF YES,DATE <br /> � [:] M M � D D Y Y .. ee <br /> SOURCE OF DISCHARGE CAUSE(S) n <br /> ¢N ❑ TANK LEAK ❑ UNKNOWN OVERFILL [:] RUPTURE/FAILURE ❑ SPILL <br /> 0 0 ❑ PIPING LEAK ❑ OTHER <br /> ❑ CORROSION ❑ UNKNOWN THER <br /> w Lu <br /> ONE ONLY <br /> U ❑ ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> ❑ UNDETERMINED SOIL ONLY <br /> CHECK ONE ONLY POLLUTION CHARACTERIZATION <br /> w m ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ <br /> ❑ ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ja ❑ LEAK BEING CONFIRMED PRE ARY SITE ASSESSMENT UNDERWAY <br /> 0 CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> ❑ REMEDIATION PLAN <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ <br /> REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> a z VENT SOIL(VS) <br /> (SEE9ACKFMDETAL4, PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) „ <br /> ❑ CAP SITE(CD) ❑ EXCAVATE 8 TREAT(ET) ❑ <br /> o O NO ACTION REQUIRED(N ❑ TREATMENT AT HOOKUP(HU) <br /> U ❑ CONTAINMENT BARRIER(CB) ❑ <br /> a <br /> Q <br /> ❑ VACUUM EXTRACT(VE) THER(OT) C/ <br /> v, Oki <br /> z <br /> a <br /> Lu0 <br /> 0 <br /> U <br /> co <br /> HSC 05(&50) <br />