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ag' /-L8n3 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? )HEREBY CEFMFYTHAT 1 HAVE DISTRIBUTED'THIS INFORMATION ACCORDING TOTHE <br /> ❑ YES NO F YES NO <br /> DESTRIBUTION SH N ON.THE INSTRUCT SH ON THE BACK PAGE OF THIS FOHM. <br /> REPORT DATE CASE <br /> M M Y N� � r DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> + f�` w `� S c k deo )lt6?-,39`3 <br /> w REPRESENTING F1 OWNER/OPERATOR E-1 REGIONAL HOARD COMPANY OR AGENCY NAME <br /> p LOCAL AGENCY OTHER S44-c H S H D. <br /> ADDRESS O Cl <br /> 51'REET OITY STATE ZIP <br /> JNAME CONTACT PERSON /� !PHONE <br /> z UNKNOWN lad G S� [N !63::5a.57 <br /> ¢ <br /> o <br /> � <br /> a ADDRESS <br /> STREET CfTY STATE ZIFI <br /> FACILITY NAME ff APPLICABLE) OPERATOR PHONE <br /> ADDRESS ck4* �S, <br /> 0 <br /> ul a �D STREEf G(TY COVNTY Z!P <br /> N CRO S STREET <br /> gy�0 h <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> U s� 14D. Res doq7,'1br-393 <br /> w w REGIONAL BOARI; � PHONE <br /> 4 4 rte,J[ C, t ? <br /> y (1} NAME QUANTITY LOST(GALLON <br /> LU <br /> O j ,Q UNKNOWN <br /> CO° (z) <br /> 0 Z <br /> UNKNOWN <br /> !- DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> z I <br /> 0M1 17MI 1 DI 3D1 (7,1 Y El TANK TEST TANK REMOVAL r OTHER <br /> r <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a_ <br /> } UNKNOWN REMOVE CONTENTS CLOSE TANK&REMOVE E::)REPAIR PIPING <br /> Q M M D Y Y <br /> W <br /> > HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK E CLOSE TANK&FILL IN PLACE E CHANGE PROCEDURE <br /> O <br /> co YES 0 NO IF YES,DATE QM u� �D � �Y Y E REPLACE TANK � OTHER <br /> 0 <br /> Lu OURC OF DISCHARGE CAUSE(S) <br /> aTANK LEAK UNKNOWN OVERFILL RUPTURFIFAILURE SPILL <br /> o PIPING LEAK 0 OTHER F_� CORROSION UNKNOWN Q OTHER <br /> w a CHECK ONE ONLY <br /> U UNDETERMINED SOIL ONLY GROUNDWATER DRINKING WATER -{CHECK ONLY IF WATER WELLS HAVE AC7UALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z c NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED 0 POLLUTION CHARACTERIZATION <br /> ff❑��LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> O REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE AGTION(S) a EXCAVATE&DISPOSE(EO) 0 REMOVE FREE PRODUCT(FP) E] ENHANCED BIO DEGRADATION(IT) <br /> J IgE BKA FM DUALS) <br /> 50 0 CAP S7E(CDj 0 EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT)0 REPLACE SUPPLY(RS) {}� <br /> ❑ CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) 7REATME'N,',F,,A,T,H-O_O^K�UP(HU) VENT SOIL(VS) <br /> a 0 VACUUM EXTRACT(VE) OTHER(OT) -s I to Q SSS ess//Lf���(J. AW <br /> z (( t <br /> HSC a5(aW <br />