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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY / YES NO <br /> HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> C�,r/ REPORT BEEN[FILED <br /> YES NO 1 HEREBY CERTIFY THAT 1 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 a �--/7� j <br /> VM rrAI � I Y ✓ `e NlED DATE <br /> NAME OF DIV AL FILING R RT ONE SIG TURE <br /> m � <br /> REPRESENTING W R/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> p ❑ LOCAL AGENCY ❑ O'TRfR <br /> Q ADDRESS <br /> CITY ' (,,.���_J STATE �f�t- ZIP <br /> Lu NAME p l� CONTP N (PHONE n <br /> U) lJ ❑ UNKNOWN �S ✓rp / <br /> o¢ <br /> a a ADDRESS <br /> N a l 1ST ET "� ` �" <br /> w <br /> CITY STATE �- <br /> IP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> z -� cl <br /> 0 <br /> ADDRESS <br /> O <br /> w CITU CO NTY ZI <br /> CROSS ST ET � <br /> �, <br /> LOCALJG NOY A ENCY NAME CORTACT PERSON PHONE <br /> z m _ ^ <br /> z <br /> Lu z <br /> w w _- <br /> J� REGIONAL BOA PHONE <br /> a a <br /> U) (t) NAME QUANTITY LOST(GALLONS) <br /> z C (l ( ❑ UNKNOWN <br /> Q J <br /> U) <br /> 0 <br /> z (2) <br /> 7 <br /> U) ❑ <br /> UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MO ORING"" ❑ NUISANCE CONDITIONS <br /> 1 /�J�//1v^y/ TANK TEST TANK REMOVAL THER ZLvL <br /> uj ®MI 1 MI —nl`' DI G Y ❑ ❑ <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> a <br /> M o o Y <br /> I„ REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> ❑ UNKNOWN ❑ <br /> p HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE CH NGE PROCEDURE <br /> o [Y€S ❑ NO IF YES,DATE vMl M1 o o Y ❑REPLACE TANK EgOTPER S <br /> L11 SOURCE OF DISCHARGE CAUSE(S) <br /> ¢5 ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> ONO E::] PIPING LEAK THER ❑ CORROSION ❑ UNKNOWN �-'OTHER <br /> ww CHECK ONE ONLY L� Z <br /> L)� ❑ UNDETERMINED ❑ OIL ONLY ❑ GROUNDW ERRINK(WATER �ON ER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> Lu <br /> 2 <br /> F ❑ LEAK BEING CONFIRMED F-] PRELIMINARYSITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) E::] CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J (SEE BALK WR DETALS) <br /> 0 o ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w� <br /> a CONTAINMENT BARRIER CB NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP HU) VENT SOIL(VS) <br /> ❑ c ) <br /> VA(VjUM. FfA&(vo 7r i '<' ,s OTHER(OT) <br /> n� <br /> zru— - 2-- <br /> w w J A N 2, 7 X992 �.-'� o <br /> ENVIRONMENTAL HEALTH <br /> TH- <br /> 1 I L HSC 05(890) <br />