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0 i 9v-vla6 <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SER <br />ES <br />FOR LOCALAGENCYUSE ONLY - <br />❑ <br />REPORT BEEN FILED? <br />YES NO VES <br />❑ <br />NO <br />I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br />DISTRIBUTION SHOWN N THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br />REPORTDATE <br />CASE t <br />v <br />SIGNED DATE <br />NAME OF INDIVIDUALII PORT <br />PHONE <br />SIGNATURE <br />w <br />REPFIE!5W6G ❑ OWNER/OPERATOR ❑ REGIONAL BOARD I <br />COMPANY OR AGE CY NAM <br />¢ <br />❑ OTHER <br />�M <br />S <br />LOCALAGENCY <br />. v <br />¢ <br />ADDRESS <br />J STREET r.�Q.K <br />U V CRv na <br />j <br />AME <br />CONTACT PERSON <br />yP�HOONNE <br />-7oz-3 <br />� <br />0 <br />a a <br />ADDRESS <br />w <br />¢ <br />(� CiSiREEf <br />CRY STAT IP <br />AGILITY NAME (IF APPLICABLE) <br />OPERATOR PHONE <br />J4c IjmrA <br />z <br />ti <br />ADDRESS <br />O <br />W <br />BTREEf <br />C wuI ZIP <br />FyOROSS <br />STREET <br />`iGS S✓ f� <br />O <br />LOCAL AGENCY NAME <br />CONTACTPERSON <br />PHONE <br />Zy <br />Z w <br />-AGENCY <br />c <br />6uA,AEy Cld— <br />(moi- <br />) 6 <br />w� <br />REGIONAL BOARD <br />PHONE <br />n a <br />(7) NAME QUANTITY LOST (GALLON <br />y <br />Z w <br />a <br />UNKNOWN <br />(2) <br />m i <br />vi <br />❑ UNKNOWN <br />i <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING NUISANCE CONDITIONS <br />SM o Zo v r <br />❑ TANKTEST ❑ TANK REMOVAL ❑ OTHER <br />a <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />UNKNOWN <br />❑ REMOVE CONTENTS ❑ CLOSE TANK& REMOVE ❑ REPAIR PIPING <br />M D Y Y <br />HAS DISCHARGE BEEN STOPPED? <br />❑ REPAIR TANK ❑CLOSE TANK& FILL IN PUKE E] CHANGE PROCEDURE <br />o <br />❑ YES d0 IFYES,DATE <br />❑ REPLACE TANK ❑ OTHER <br />M M D <br />r r <br />SOURCE OF DISCHARGE CAUSES) <br />0, <br />0, <br />E] �p11EEAK UNKNOWN <br />❑ OVERFILL fjVPNRE/FAILURE ❑ SPILL <br />'I-4A'd IIP`ING LEAK ❑ OTHER <br />❑ CORROSION UNKNOWN ❑ OTHER <br />w w <br />CHECK ONLY <br />UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECKONEOONLY <br />wZ <br />❑j16 ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />MEDPRELIMINARY MONITORING IN PROGRESS <br />= y <br />C <br />CLOSED ( EANUP COMP ETED OR UNNECESSARY) ❑ CLOEANUPNDE WAy <br />F-1 REMEDIAE] CASE <br />N pry PLAN <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE& DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (M <br />az <br />IS1�fl�GMfMRFM� <br />❑ CAP SITE (CD) E]EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />00 <br />wr <br />� <br />❑ CONTAINMENT BARRIER (CB) ❑ ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />❑ VACUUM EXTRACT (VE) Yr OTHER (OT) <br />z <br />w <br />