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q�� —a rcz , <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YENO YES NO <br /> REPORT BEEN FILED 7 I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> S ❑ <br /> DISTWUP SHOWN E INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM: <br /> REPORT DATE ^ CASES <br /> OM / MI D Y SGN�JY— --- 6fDATE (f! <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNA <br /> > S SS's bog) �6���yS .S <br /> m <br /> REPRE ENTING OWNER/OPERATOR ❑ REGIONAL BOARD CO ANY OR AGENCY NAME <br /> 0cLOCALAGENCY [:] OTHER <br /> Q ADDRESS D ew <br /> zaql �\ <br /> V V �3TREET CRY STATE ZIP \n\ <br /> w NAM/E� CON <br /> TA <br /> CT PER ON �j PHONE <br /> Q Q Q \V\ <br /> E, / I ❑ UNKNOWN //"/ ✓ ��`�/���� / ! V <br /> Q <br /> ADDRES <br /> COS 3o a—S�o �SGI'�'J Se, Grt <br /> w Zf <br /> STREET CRY STATE <br /> FACILITY E(IF APPLICABLE) OPERATOR PHONE O <br /> Z Ke--o �# 0218 CLD c <br /> UADDRESS <br /> � 10(" <br /> �yo;n '/)/'�^�s raE / VVVI�VC�. VL I ZIP <br /> w C/r� <br /> N CROSS;711 , <br /> ;AL AGENCY AGENCY NAME CONTACTPERSON PHONE <br /> '' �i �v �/ <br /> r-w <br /> Z_ <br /> Lu <br /> w w REGIONAL BO PHONE <br /> J C7 <br /> m (1) NAME QUANTITY LOST(GALLONS) <br /> W <br /> U w UNKNOWN <br /> Z <br /> Q J <br /> m O (Z) <br /> �Z <br /> a UNKNOWN <br /> r DATE DISCOVERED Q q HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 0MI U MI 1D1 v D1 ` Y Y ❑ TANK TEST ❑ TANK REMOVAL OTHER <br /> CD <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> Q UNKNOWN REMOVE CONTENTS ❑CLOSE TANK 8 REMOVE ❑REPAIR PIPING <br /> w M M D D Y Y <br /> p HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK a CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> U) ❑ YES NO IF YES.DATE ❑REPLACE TANK ❑ OTHER <br /> M MI D V Y <br /> � SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> CC 5 <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL +❑ RUPTURE/FAILURE ❑ SPILL <br /> � <br /> O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION 3G I UNKNOWN OTHER <br /> co a CHECK ONE ONLY <br /> O ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w F7 NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> cc <br /> cc ❑ 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) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> J (SEE 9ACK FCR MALS) <br /> a Z <br /> o O F-1CAP SITE(CO) F-] EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> Lu <br /> w a ❑ CONTAINMENT BARRIER(CB) E:] NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) <br /> Zui <br /> ap? G� <br /> l(oq 1114 r <br /> HSC 05("0) <br />