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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? YES �NQ i HEREBY:CE FY?HAT)HAVE TRIBUTEDTHIS INFORMATION ACCORDING TO THE <br /> 0 YES �O D T SHOWN ON TH UCTION SHEET ON THE BACK PAGE OF T 1.11S FORM. <br /> REPORT DATI La _ <br /> M MI d ul <br /> NAF INDIVIDUAL F ING REP R `S_ PHONE SIGN R <br /> ME <br /> m a C ANY OR AGENCY NAME <br /> REPRESENTING OWNERtCPERATOR REGIONAL BOARD <br /> w <br /> p �LDCALAGENCY OTHER )J( <br /> LU <br /> a <br /> DRESS <br /> V"! v!I cm srATE QIP <br /> STREET <br /> w NA E CONTACT PERSON PHONE <br /> Oaks t <br /> Za UNKNOWN <br /> os <br /> a ADDRESS <br /> - C STATE IP <br /> 10 J <br /> FACT IlY NAM (IF APPLICABLe OPERATOR PHONE <br /> Z <br /> 0 ADDRESS J//�// l/\' , <br /> OJ STREET g 7✓ S C `-ou 21P <br /> w <br /> CROSS STREET <br /> i rd <br /> CONT CT PERS PHONE <br /> 0 AL AG AGENCY NAME n- /� ) 2d <br /> At S�Z <br /> Zz: <br /> U <br /> LU PHONE <br /> w w RE ZONAL BOAR <br /> 1 <br /> NAME QUANTITY LOST(GALLON <br /> U)p ( 1 /� 1� ,^,A UNKNOWN <br /> a� <br /> ca Z( 2) UNKNOWN <br /> z DATE DISCOVERED DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> LU LU IMI MI ODJ DI YI �HOW <br /> TANK TEST TANK REMOVAL O OTHER <br /> a METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> CD DATE DISCHARGE BEGAN <br /> a UNKNOWN REMOVE CONTENTS CLOSE TANK 3 REMOVE REPAIR PIPING <br /> } <br /> *HASDISCHARG�E <br /> D Y IY <br /> LU a REPAIR TANK CLOSE TANK&FILL IN PLACE 0 CHANGE PROCEDURE <br /> 0 <br /> BEENSTOPPED 7 REPLACE TANK OTHER <br /> oS NO IF YES,DATE 1M <br /> MI D r1 r <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> j TANK LEAK UNKNOWN OVERFILL O RUPTURE/FAILURE SPILL <br /> u0i 0 F7 PIPING LEAK a OTHER Q CORROSION UNKNOWN OTHER <br /> w w CHECK ONE ONLY <br /> U UNDETERMINED OIL ONLY Q GROUNDWATER 0 DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z a NO ACTION TAKEN a PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED 0 POLLUTION CHARACTERIZATION <br /> Uj <br /> cc <br /> cr ra LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> a w REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) a CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE 6 DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIODEGRADATION(IT) <br /> Isrf S�CX POR oer,us <br /> a Z CAP SITE(CO) EXCAVATE 6 TREAT(ET) PUMP b TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> 2 o CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) TREATMEN7 AT HOOKUP(HU) VENT SOIL(VS) <br /> O VACUUM EXTRACT(VE) OTHER(OT) <br /> cn <br /> z <br /> w <br /> 0 <br /> U <br /> HSC 05 1eW <br />