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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES ':, <br /> .TORIOCALIGENCTUSE ONLY <br /> REPORT BEEN FILED? <br /> YES NO YES 0 1 HEREBY.CEFMRYTHAT 1:-HAVE DIS 0❑ - <br /> IN8TRU.CTPN SHEq CA THE 13ACK PAGE TH 1SF95A <br /> REPORT DA TF/ ASE a. <br /> NAME Or INDIVIDUAL FILi REPORT PHONE SIGNA <br /> "oe—=:,ei (ZO-1) <br /> REPRESENTING F-1 OWNEPJOPERATOR ❑ REGIONAL BOARD ARD COMPANYOR AGENCY NAME <br /> ,. <br /> OCAL AGENCY 0 OTHER <br /> R <br /> SS <br /> Lu <br /> cc DRESS <br /> 04AI gp L-z;,�J <br /> STREET erry STATE ZIP <br /> Lu NAMECONTACT PERSON PHONE <br /> UNKNOWN <br /> 00 <br /> Wo- ADDRESS -�lo <br /> uj <br /> STREET CITY STATE IP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o, 7Z 7 <br /> ADDRESS <br /> L) <br /> STREET Wry COUNTY ZIP <br /> t <br /> CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> - o ,, <br /> Lo <br /> z <br /> ujo PHONE <br /> Mz <br /> L REGIONAL BOARD <br /> as <br /> NAME QUANTITY LOST(GALLON <br /> UNKNOWN <br /> Z> <br /> ;5� <br /> 0 <br /> > (2) <br /> :D Z ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED El INVENTORY CONTROL ❑ SUBSURFACE MONITORING Ej NUISANCE CONDITIONS <br /> w <br /> E:] TANK TEST $rTANK REMOVAL Ej OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> KNOWN ❑ <br /> � <br /> REMOVE CCNTENTS LOSE TANK&REMOVE E]REPAIR PIPING <br /> [::] <br /> uj <br /> I DI Yl yl <br /> > Ej .-HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TAN / <br /> 0 CLOSE TANK FILL IN PLACE ❑CHANGE PROCEDURE <br /> 0 ❑Ln —] OTHER❑ YES E] NO IF YES, .1 ml 1,1 E]REPLACE TANK E_ <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ❑L <br /> 5 W <br /> cc TANK LEAK UNKNOWN ❑ OVERFILL E] RUIPTUREfFAILURE ❑ SPILL <br /> 6 OTHER UNKNOWN E] OTHER <br /> 0 F--j PIPING LEAK F❑ CORROSION <br /> w w CHECK ONE ONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z <br /> �- F--j NO ACTION TAKEN U, ❑ PRGLIMtNARYSITE ASSESSMENT WORKPLAN SUBMITTED E:] POLLUTION CHARACTERIZATION <br /> w <br /> ❑cc ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY <br /> POST CLEANUP MONITORING IN PROGRESS <br /> 3'n ❑ <br /> 0 REMEDIATION PLAN F--] CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) E:: CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) E::] REMOVE FREE PRODUCT(FP) E] ENHANCED BIODEGRADATION(11) <br /> (W-R BACK FMOLTAIA) <br /> z ❑ CAP SITE(CD) E] EXCAVATE&TREAT(ST) ❑ PUMPS TREAT GROUNDWATER(GT)E:] REPLACE SUPPLY(RS) <br /> 00 <br /> LLI <br /> 2 C) CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) E] TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> F—] VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> le ,a e5ee-,,P94& <br /> z 111,4 7/.o <br /> Lu <br /> 0 e <br /> HSC 05(b" <br />