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UNDERGROUND STORAGE TANK(UST) SITE • UNAUTHORIZED RELEASE/CONTAMINATION REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑Yes KNO REPORT BEEN FILED? IxYes ❑No 1 HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TOS EIIN <br /> 2 181)7O <br /> �� <br /> 7 OF <br /> REPO DA'lECASE# THE HEALTH AND SAFETY 11 //// <br /> ftA'qqliSIGNED DATE <br /> Ni OF INDIVID AL FI GREPORT PHONE SIGNATURE <br /> s ) 1�0 ✓IJ <br /> RESENTING r C MPANY OR AGENCY NAME <br /> 0 OWNERI PERA NCY ❑REGIONAL BOARD <br /> o OWNER/OPERATOR ❑OTHER V n <br /> s ADfJJR(ESS <br /> CITY STATE ZIP <br /> y NAME <br /> J:/�J(/� ❑ ` HONE <br /> UnknownnIM- iI ( <br /> ADDRCYY\\d <br /> %2s�)STREET STATE <br /> s <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> J <br /> DRESS _ <br /> TRFET•� /�/{T�}'(�g(� �ZIP <br /> CRQSTREET <br /> z/ 5e <br /> � <br /> LOCALAGENCY AGENCY NAME PHONE <br /> o REqONAL BOARD V PHONE l7 <br /> ` (9ib�y6�1 U <br /> (1) 7 NAME QUANTITY LOST(GALLONS) <br /> W O / ❑ Unknown <br /> j i <br /> (2) <br /> :n 'eUnknown <br /> DATE DISC VERED HOW DISCOVERED EJ ❑ ❑Nuisance Conditions <br /> Tank Tesl Tank Removal <br /> w �� ❑Inventory Control ❑Subsurface Monitoring OUler <br /> DATE DISCHARGE BE N METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> y ❑Remove Contents ❑ Close Tank <br /> `x Unknown ❑Repair Tank ❑Change Procedure <br /> o HAS DISCtLARQE BEEN STOPPED? ❑ Replace Tank Other <br /> y TTT"`��� <br /> iS ❑Yes AND IF YES,DATE ❑ Repair Piping <br /> J w SOURCE OF DISCHARGE CAUSE(S) <br /> Uy <br /> Tank Piping ❑Dispenser ❑Delivery Problem ❑Spill ❑Overfill ❑PhysicallMec ni al Dama a ❑Corrosion <br /> m Subm rslbie Turbine Pump(STP) ❑Other ❑Installation Problem ❑Unknown Other A�1 <br /> CHECK ONE ONLY <br /> nn <br /> Undetermined ❑Sal Only ❑Groundwater ❑Drinking Water-(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> i ❑Open-Site Assessment ❑Open-Verification Monitoring <br /> pa ❑Open-Assessment&Interim Remedial Action C]Open-Inactive <br /> a m Open-Remediation ❑Closed-No Further Action Required <br /> V <br /> z CHECK APPROPRIATE ACTIONS) <br /> Human health exposure control? O Yes ❑No [Unknown <br /> P <br /> Groundwater migration control? ❑Yes ❑No 'Wnknown <br /> ❑No Action Required(NAR) ❑Excavate&Treat(ET) ❑Treatment at Hookup(TH) ❑Other <br /> y ❑Excavate&Dispose(ED) ❑Free Product Removal(FPR) ❑Replace Supply IRS) <br /> s <br /> y Cul (ll +/trial by CQI Tr"M LLQ" Gt e("tn4i� <br /> = u <br /> f <br /> J <br /> J <br /> ,NR( It I rak itr puri Prim. htt P://www.swrcb.ca.guv/water_issues/programs/ust/forms/ Res.02/01/2012 <br />