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d uc c� <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY. <br /> REPORT BEEN FILED 7 <br /> [—I VES NO ❑ VES NO 1HEREBY CERfIFYTHATI HAVE DISTRIBUTED THIS INFORMATION ACCORDING T07HE <br /> REPORT DATECASE t DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> QM M l D _y SIGNED DATE <br /> ME OF INDIVIDUAL FILING REPORT PHONE SIGNA <br /> ELl <br /> w REPRES ❑ E]H. REGIONAL BOARD PANY OR AGENCY NAME <br /> S LE ING OWNEROPERATOR OCALAGENCY ❑ OTHER �OQ <br /> ADDRESS <br /> 3 �C _ ( ���P✓L� It �- �C\+ \�`l� Jl- S ZQ Z. <br /> ""' STATE 21P <br /> j NAME CONTACTPERSON PHONE <br /> 59 <br /> 0z UNKNOWN <br /> c <br /> ma ADDRESS G <br /> crtv t rZ-62. <br /> ST1TE P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> O <br /> < ADDRESS <br /> x CR SS STREET <br /> / ZIP <br /> Ll,t <br /> 0 LOCALAGENCY AGENCY NAME CONTACTPERS N <br /> z W C �6� , ` Ver PHONE <br /> w w REGIONAL BOARD N O` �I <br /> O PHONE <br /> as <br /> NAME <br /> U O � QUANTITY LOST(GALLONS) <br /> w <br /> r 0 �, ❑ UNKNOWN <br /> m o> (2) <br /> N Z <br /> ❑ UNKNOWN <br /> W DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUI9*CE CONDITIONS <br /> /�/'. <br /> O <br /> MI ul o \.1. oYR v ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER C/IYJ�J <br /> Q DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) 1(�' <br /> w u D YI T UNKNOWN ❑REMOVE CONTENTS ,O CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED 7 JJ"❑REPAIR TANK > LOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> S VES ❑ NO IF YES,DATE M MI o r Y ❑REPLACE TANK --" OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢Q ❑ TANK LEAK -UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> ww CHECK ONE ONLY <br /> O UNDETERMINEDSOIL ONLY <br /> ❑ ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ¢� ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> y ❑ LEAN BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATES DISPOSE(EO) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> 1=EERO APPROPRIATE <br /> 81 <br /> a z CAP SITE CD <br /> w O ❑ ( 1 ❑ EXCAVATE d TREAT(ET) ❑ PUMP d TREAT GROUNDWATER(GT) REPLACE SUPPLY(RSI <br /> r <br /> a ❑ CONTAINMENT BARRIER ICE) ❑ NO ACTION REQUIRED INA) ❑ TREATMENTAT HOOKUP(HU) ❑ VENTSOIL(VS) <br /> ❑ VACUUM EXTRACT NE ❑ OTHER(OT) <br /> z <br /> z <br /> w <br /> F <br /> 0 <br /> 0 <br /> U <br /> HSC 0.5199% <br />