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UNDERGROUND STORAGE TANK(UST)SITE- UNAUTHORIZED RELEASE/ CONT A ' IN 0 � � <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE <br /> ON <br /> REPORTREPO <br /> LY ORT <br /> 11 Yes NO REPORT BEEN FILED? ❑Yes 0 I HEREBY CERTIFY THAT I AMA DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> TE CASE# REPORTED THIS INFORMATION TO LOCAL OFF,CIALS PURSUANT TO SECTION 25180.7 OF <br /> 1-/3ol2o1L+ <br /> THE HEA THA ND SAFETY CODE. L� <br /> NAME OF INDIVIDUAL FILING REPORT SIG <br /> PHONE SIG URE DATE <br /> 3e f-Fr L/J 0 r <br /> o REPRESENTING <br /> LOCAL AGENCY COMPANYORAGEN NAM ' <br /> ❑REGIONAL BOARD <br /> o U OWNERIOPERATOR ❑OTHER <br /> iM <br /> ADDRESS/ /� /y/-�(��I /�^ p r <br /> ,6 b jj STREET �� 0. -f�a� lGc -& r C A 7f�ZdJ <br /> w NAME I CITY STATE ZIP <br /> m tl 1 I Co Lm``I f'1 (; I COM;' PE SON PHONE <br /> o¢ ADDRESS LOthX. 1 ` 1 /ni4❑ Unknown �"2�� S53 3i;1 <br /> 2-255 N. l�Atcirto j $4e22D Burbank CA Il � <br /> STREET CITY <br /> FACILITY NA1ME(IF APPLICABLE) STATE ZI/� <br /> "1 0 OPERA <br /> L` rt -/ PHONE <br /> ADDRESS lA, (A ( .�,�'O 3�'� <br /> U <br /> ! SD �. Uleber 5 �ac �fcrn CA 9 <br /> v-i CROSS STREET STREET CITY COUNTY Zo s <br /> ZIP <br /> LOCALAGENCY AGENCY NAME <br /> �N <br /> PHONE <br /> w Jo �n C6ctn-� �n vrv+�hryt¢ �ifY� (Zoq) W g 03 3<j <br /> w REGIONAL BOARD <br /> a¢ <br /> PHONE <br /> NAME ( ) <br /> cwi w *��, QUANTITY LOST(GALLONS) <br /> z> L <br /> m� (2) C '© —cls) Wunknown <br /> Ma (or 0;1 Runaz (:_ C24 -C36) <br /> DATE DISCOVERED ❑ Unknown <br /> w /1 HOW DISCOVERED 0 Tank Test <br /> ❑Tank Removal ❑Nuisance Conditions <br /> w <br /> m DATE DISCHARGE BEGAN Inventory Control ❑Subsurface Monitoring ther <br /> a METHOD USED TO STOP DISCHARGE(CHECKALL I HAT APPLY) <br /> Remove Contents <br /> ,I�S�'` tClose Tank <br /> onknown L_J Repair Tank Change Procedure <br /> � HAS DISCHARGE BEEN STOPPED? <br /> `-' ❑ Replace Tank Other <br /> E3 Yes [:] No IF YES,DATE SVy71-Q V�1-l.i� ri U11r�Z1 <br /> i1i w SOURCE OF DISCHARGE ❑ Repair Piping <br /> m CAUSES) <br /> D< Tank ❑piping ❑Dispenser ❑Delivery Problem <br /> yr Submersible Turbine Pump(STP) ❑Other pill EJ Overfill ❑physical/Mechan!Cal Damage ❑Corrosion <br /> ❑Installa0on Problema Unknown ❑Other <br /> W w CHECK ONE ONLY <br /> Qa <br /> El Undetermined El Soil onlyGroundwater ❑Drinking Water-(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> ,sC�HECK ONE ONLY <br /> a0pen-Site Assessment <br /> � ya ❑Open-Verification Monitoring <br /> F L7 Open-Assessment&Interim Remedial Action El Open-Inactive <br /> U N <br /> 11 Open-Remediation <br /> ❑Closed-No Further Action Requiretl <br /> i CHECK APPROPRIATE ACTIONS) <br /> o Human health exposure control? ❑Yes <br /> 0 Groundwater migration control? ❑Yes ❑No ' Unknovm <br /> S ❑No Action Required(NAR) ❑Excavate&Treat(ET) El <br /> KExcavate&Dispose(ED) ❑Free Product Removal FPR Treatment at Hookup(TH) ❑Other <br /> rc (FPR) ❑Replace Supply(RS) <br /> w }L4�i 6v1 -Q"�_C0'U 0.4ff6A Cit y\ US% P011-S C6'ACL"C-kc( � <br /> o <br /> ddo, d d sco to <br /> U CGL /1 -s�[ I"l I S-Q" r:n T)-�-> cp. n <br /> �- L /'-fflQQ� OJei�-Q.)CC0.U�-�ic(Y1 , <br /> SWR__Leak Report Form http://www.swreb.ca.gev/water-issues/programs/ust/forms/ <br /> Rev.02/01/2012 <br />