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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SrTE_REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY.. <br /> ❑ YES ❑ NO REPORT BEEN FILED? , �NO� / <br /> ED vEs �yI NS IBYCERfIFYTHATI HAS�QIS7RIBUTED THIS INFORMATION ACCORDING TO THE <br /> REPORT DATE <br /> O M M CASE* , /� ,^ E"NSIRDCflDN'SHEEZON TF s'i"'d �r FM <br /> w NAME OF SGKD <br /> T PHONE ' <br /> SIGNATURE <br /> ` <br /> DAT <br /> REPRESENTING <br /> NERA7PERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY E / <br /> S ❑ LOCALAGENjjCY O OTHER v cn <br /> Fc ADDRESS (9 _ ®^ 6 O3 8 S <br /> STREET / � qoo 03 8 <br /> cm STATE <br /> m NAME CONTACT PERSO PHONE ZIP <br /> z � `� u"•J UNKNOWN /." ( r-, 1 / <br /> n ADDRESS Q`D (�((� 2 <br /> C 7 L/_�C STREEf / J G q -� O V V <br /> FAC ITV NAME(IF APPLICABLE) <br /> o ^ OP ATOR <br /> 5 U// {r /PHONE <br /> a <br /> ADDRESSr <br /> WQ►- Cal-Crczvh Q WIT <br /> �il STREET CRYNry <br /> sY6 µ(y <br /> y CROSS STREET ( P /-yT <br /> -j-KG�cC� Pip JZJ <br /> Z LOCALAGENCY AGENCYNAME CONTACTPE SON PHONE <br /> z Sa ©a �(' Lo o �i11 1020 8 - o <br /> I,,w REGIONAL BO PHONE <br /> � ( I <br /> NAME <br /> U p OUANTI LO <br /> R <br /> R) T(GALLONS) <br /> w ( n <br /> �R S ( �(� Q ❑ UNKNOWN <br /> m <br /> N <br /> DATE DISCOVERED <br /> E:] UNKNOWN <br /> i HOW DISCOVERED ❑ INVENTORY CONTROL O SU RFAC MONITORING O ANCE CONDITIONS <br /> D ❑qLjw <br /> TANK TEST ❑ TANK REMOVAL OTHER P <br /> u D Y <br /> a DATE D19CIARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPL <br /> w M D ❑ UNKNOWN ❑REMOVE CONTENTS O CLOSE TANK b REMOVE Q REPAIR PIPING <br /> HAS DIS H E BEEN STOPP 7 REPAIR TANK CLO AN b ILL IN LACE <br /> ❑ ❑ ❑CHANGE P EDURE <br /> O YES ❑ NOIFYES,DATEo 1 ❑REPLACE TANK THER e <br /> M ule ___111 Y Y <br /> SOURCE OF DISCHARGE CAUSE(S) I- <br /> wrl <br /> aj ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURFJFAILURE O SPILL <br /> w O ❑ PIPING LEAK O OTHER ❑ CORROSION ❑ UNKNOWN DROTHER <br /> w w CHECK ONE ONLY If <br /> a <br /> O ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ❑ NO ACTION TAKEN ❑ PRELI ARV SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION y ' <br /> mm ❑ LEAK BEING CONFIRMED ❑ LIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE b DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(M <br /> ISE saxronoerus <br /> a ❑ CAP SITE(CO) ❑ EXCAVATE b TREAT(ET) ❑ PUMP b TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w0 <br /> a EN <br /> ❑ CONTAINMENT BARRIER(CB) ❑ TK)N REOUI D IN ❑ TRE; ENT AT H P(HU), a ENT SOIL(VS) <br /> /❑ VACUUM <br /> EXTRACT(VE) �/ q OTHELR(OT) <br /> i yV l/ (/V. s 0 LL✓i /L � Q� <br /> GLGiL�j knaI'mkel� <br /> JN9C W IIM)l <br /> cc , kyr <br />