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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> YES NO <br /> REPORT BEEN FILED? YES NO <br /> 1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> � � � <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. <br /> REPORT DATE�/ CASE s /y�j / <br /> OMI v ' t �l '�—' SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE S A RE <br /> m <br /> w REPRESENTING a OWNEFVOPERATOR REGIONAL BOARDCOMPANY OR AGENCY NAME n <br /> RLOCAL AGENCY ❑ OTHER Gly+ f �4[i1 <br /> s ADDRESS / //(CCClIlJJJ <br /> OFL- <br /> CRY STATE ZIP <br /> JNAME//1 {C/OONNTT/A��_1CT PERSON yyf�i PHONE <br /> n7 nI <br /> Z Q UNKNOWNAt <br /> a a ADDRESS <br /> cc <br /> 7t/)/ x/r/410Er��z fTy STATE ZIP <br /> FACILITY NAME(IF APPLICAB OPERATOR PHONE <br /> Z / <br /> ADDRESS n <br /> ° 6I E (�%�� ' CLti� L/ �?r JDr <br /> � INJ�T/IMJ L/T <br /> < v�'r, <br /> w UNTY IP <br /> m CROSS STREET <br /> S'1017 <br /> Z L AL AGENY AGENCY NAM CONTACT PERSON PHONE <br /> w %% C®l�n'� E .�T v�n� -� 14f 511-1 AJE�n9) 6 3�sQ <br /> w w REGIONAL BOA PHONE <br /> NAME QUANTITY LOST(GALLONS) <br /> UJw <br /> O �v v V UNKNOWN <br /> m Z m <br /> UNKNOWN <br /> Z DATE D�0.1 <br /> VERED HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING El NUISANCE CONDITIONS <br /> Lu / <br /> w O W / D r� r ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> M o r r <br /> LM <br /> cc UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED? F7 REPAIR TANK <br /> U <br /> El TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> ❑ YESNO IF YES,DATE MI MI o rI r F7 REPLACE TANK OTHER <br /> SOURCE OF DISCHARGE �,( CAUSE(S) <br /> ja ❑ TANK LEAK I XI UNKNOWN OVERFILL RUPTURE FAILURE a SPILL <br /> U ❑ PIPING LEAK f❑� OTHER CORROSION UNKNOWN O OTHER <br /> Lu w CHECK ONE ONLY SYY�YYY <br /> N D. <br /> v UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER •(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Lu <br /> NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> cr ti cc <br /> LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> (SEE MGK Fdi OETAl3) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> � <br /> o O CAP SITE(CO) ❑ EXCAVATE&TREAT(ET) PUMP d TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> Z <br /> f <br /> O <br /> U <br /> HSC 05(8," <br />