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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY - <br /> YES NO REPORT BEEN FILED? YES 0 NO 1 HEREBY CERTIFYTHAT I,HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> `'/� �'] DISTR IB TION SHOWN C/I THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FCflM- <br /> REPORT <br /> / MTE o ^ ^ Y CASE, 1 3 I ,,.. . � <br /> �N DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> m <br /> R SENTING O OWNERIOP R REGIONAL BOARD COMPANYAGENCY NAM <br /> S <br /> LOCAL AGENCY O OTHER SS <br /> T p; iX a�9S RE N. Scvil jva �m s�fv c k� �. CA 1, � <br /> w NAME / CONTACTPERSON PHONE <br /> UNKNOWN W,' PL / db ? <br /> l- <br /> W I I <br /> a< ADDRESS <br /> ,ciw • STAh <br /> FACILITY NAME(IF APPLICABLE) V OPERATOR PHONE <br /> Olor b70`1193/-1 ' y` <br /> ADDRESS I �1 c0s - O t i <br /> o ///V// /D / ` v <br /> w <br /> crtY cou zIR <br /> m CROSS STREET <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> 2 y <br /> Lei- <br /> 1 w — ; w c� 15`b 3Y <br /> Z= <br /> w a REGIONAL BOARDGPHONE <br /> a a � uJ ,t3 c 1 <br /> NAME QUANTITY LOST(GALLONS) <br /> i w r UNKNOWN <br /> a <br /> m> (2) <br /> y Z <br /> O UNKNOWN <br /> F <br /> DATE DISCOVEREDHOW'?.I 9 HOW DISCOVERED O INVENTORY CONTROL O SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> mul I �q I M • Y �Y TANK TEST TANK REMOVAL OTHER <br /> m DATEDISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> c O <br /> ml <br /> M 0 Y �lT UNKNOWN O REMOVE CONTENTS CLOSE TANK 6 REMOVE O REPAIR PIPING <br /> w V l <br /> HAS DISCHARGE BEEN STOPPED 7 Q REPAIR TANK CLOSE TANK 8 FILL IN PLACE CHANGE PROCEDURE <br /> YES O NO IF VES,DATE M M .1 dY Y O REPLACE TANK Q OTHER <br /> SdURyyRCCE OF DISCHARGE CAUSE(S) <br /> DO TANK LEAK O UNKNOWN O OVERFILL 0 RUPTURE/FAIIURE � SPILL O <br /> y O PIPING LEAK O OTHER CORROSION O UNKNOWN O OTHER <br /> yw� CHECK ONE ONLY <br /> O UNDETERMINED E-] SOIL ONLY GROUNDWATER 0 DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) 7 <br /> CHECK ONE ONLY <br /> ?y NO ACTION TAKEN a PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> ¢� <br /> �y LEAK BEING CONFIRMED Q PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> O Q REMEDIATION PLAN 0 CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) 0 CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTIONS) EXCAVATE 6 DISPOSE(ED) O REMOVE FREE PRODUCT(FP) O ENHANCED BIO DEGRADATION(IT) <br /> I�eicR rw oausl Gam. <br /> a 0 CAP SITE(CD) IJ[I EXCAVATE 6 TREAT(ET) O PUMP&TREAT GROUNDWATER(GT)O REPLACE SUPPLY(RS) <br /> w a CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) O TREATMENT AT HOOKUP(HU) O VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) O OTHER(OT) <br /> ZM <br /> Tom. ti <br />