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VII <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGEN ERVICES FOR LOCAL AGENCY USE ONLY: <br /> REPORT BEEN FIIEDi 1HEHEBV CERiIFYTHATI HAVE DIST R ED THIS INFORMATION ACCORDING TO HE <br /> ❑ YES YES ❑ NO <br /> REPORT DATE DISTRIeUTI SHOWN ON TH INSTR T N ETON THE BACK PAGE O THIS M <br /> CASE s <br /> M Y 9 a <br /> ��"' 'SlcwEo <br /> NAME OF INDIVIDUAL FILI REPORT DAT <br /> PHONE SI NATU <br /> m ( I <br /> w REPRESENTING ❑ COMPANY OR AGENCY NAME <br /> r OWNER/OPERATOR ❑ REGIONAL BOARD <br /> S¢ LOCALAGENCY ❑ OTHER <br /> 1 ADDRESS \— ^ Q/�• (Y <br /> 2Lar=6 15 srREET cm <br /> STATE C-PC <br /> w NAME CONTACTPERSON PHONE nv <br /> m . <br /> Z� ❑ UNKNOWN <br /> 0an ADDRESS �G•/•71 <br /> w <br /> w <br /> S REE <br /> FACILITY NAME(IF APPLICABLE) , OPERATOR cm sTATE l <br /> / PHONE <br /> a ADDRESS <br /> U <br /> O <br /> w STREET �(n I Cm ^�- <br /> I CROSS STREET' �A 21v <br /> irn L AGENCY AGENCY NAME CONTACTPERSON PHONE <br /> w 7EA D I <br /> w= - <br /> ww REGgNAL BOARD PHONE <br /> na <br /> w NAME QUANTITY LOST(GALLONS) <br /> ❑ UNKNOWN <br /> m� m <br /> N <br /> ❑ UNKNOWN <br /> W DATE DISCOVERED HOW DISCOVERED ❑ IPENTORYCONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Oa 1 "24 Q ❑ TANKTEST TANK REMOVAL E:] OTHER <br /> D Y Y <br /> i.5 <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE�yE61(ALL THAT APPLY) <br /> w M 01 <br /> Y 11 <br /> UNKNOWN ❑REMOVE CONTENTS ur'CL/OSE TANK 8 REMOVE O REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK 8 FILL IN PLACE ❑CHANGE PROCEDURE <br /> YES ❑ NO IF YES,DATEew <br /> Y r1 Y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢j ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> 0, <br /> ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> a n 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 ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> �q ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) a CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE d DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> QZ CAP SITE <br /> wO ❑ (CD) ❑ EXCAVATEB TREAT(El) ❑ PUMP TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) E::] VENTSOIL(VS) <br /> F-1 VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> tog. W-l� <br /> O <br /> U <br /> HSC US IS'�1 <br />