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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 /> ❑ YES NO REPORT BEEN FILED ❑ YES ❑ NO 1 HEREBY CERTIFY7HAT i HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIPeTION SH N ON W CTIO SHEET ON THE RAK PAGE OF THIS FORM <br /> REPORT DATE CASE s <br /> 0.1 F-1 � ��/ FL � <br /> M M r SIGHED DATE <br /> NAME OF INDIVIDUAL FILING REPORT /PHHONNEqp ? SIGN <br /> RE7LOCAL <br /> TING F1OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY q AGENCY NAME <br /> pAGENCY [:] OTHER �Q <br /> ADDRESSVD <br /> D• !/�/O / STREET CRY Y7 V !(y/v STATE Zlp <br /> Lu NAME CONTACTPERSON PHONE <br /> J M ` <br /> z ' '! UNKNOWN <br /> >/ Q 2)O ZI QO <br /> a a ADDRESS/ //J/J� D' ^/ (///f w�/, S <br /> cr ZOOJ STREET I •, I V �/�—/' CRY �D,V STATE `"/ L �IpZO6 <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> 0 <br /> a ADDRESS <br /> Z o o s S c,4 fz Al S <br /> O STREET `'�� CRY COUNTY ! ZIP <br /> ~ CROSS STREET <br /> m <br /> 2L'E ,err/E <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z <br /> zw <br /> w <br /> w 1 REGIONAL BOA a / PHO/NE <br /> CL <br /> a L/V63 <br /> SCJ �SS LT• I ! ) <br /> N (1) NAME QUANTITY LOST( <br /> GALLONS <br /> w0zQLu <br /> J LND <br /> (2) <br /> z /3 3 Pc 8s UNKNOWN <br /> t DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lu <br /> z7 <br /> w .1 ?/J��,+.Ml 2/tj 11-D] `9 <br /> YI / Y ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> m <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> } UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK d REMOVE ❑REPAIR PIPING <br /> D: M M D D Y Y <br /> uj <br /> >O HAS DISCHARGE BEEN STOPPED 4 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> o ❑ YES ❑ NO IF YES,DATE MI MI DI oI YI r ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> a ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ R RE/FAILURE ❑ SPILL <br /> ON v ❑ PIPING LEAK 71 OTHER F7 CORROSION UNKNOWN ❑ OTHER <br /> N CL CHEnONLY <br /> TERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER •(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK 0>E-ONLY <br /> z NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w <br /> 2 <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> L> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 8 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> (SEE ecu i M7AlS) <br /> z (7O CAP SITE(CD) ❑ EXCAVATE d TREAT(ET) ❑ PUMP b TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> O <br /> w <br /> Qa ❑ CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) F7TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> w <br /> f <br /> O <br /> HSC 05(890) <br /> h < <br />