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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES N SITE REPORT <br /> YES NO REPORT BEEN FILED? FOR LOCAL AGENCY USE ONLY <br /> REPORTO TE ❑ YES NO I HEREBY CERTIFY THAT i HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE CASE x DISTRI UTION HOWN ON THE UCTION SHEET ON THE BACK PAOf THIS ORM <br /> M� F <br /> NAME JF INOIV UAL FILING REPORT SIGN <br /> 77(3-. <br /> PHONETE <br /> rm j jl] 1 } SIGNq RETIA {`�,� ��� <br /> ow REPRESENTING T I I * �(�► 1 L'�'"' jJ <br /> OWNER/OPERATOR ❑ REGIONAL BOARD C PAY R ADEN AME <br /> a OCAL AGENCY OTHER <br /> uJ <br /> cc A ESS �ll/ Eli <br /> Ilk <br /> w NAME a � jt " ' ` `^ y cm <br /> STATE <br /> CONTACT PERSON ZIP <br /> z¢ u vnGt �.n ❑ 4e rne3-t- c PHONE � <br /> a y UNKNOWN <br /> ADDRESS <br /> w PoL�Jv <br /> STgE <br /> FACILITY NAME(IF APPLICABLE) ra <br /> OPERATOR P <br /> Oz PHONE <br /> U ADDRESS <br /> V 1 ` <br /> w <br /> �x � <br /> ~—� CROSS STREET <br /> t.0 ZIP <br /> z ? IOCAL AGENCY AGENCY NAME CONTACT PERSON <br /> ~ PHONE <br /> Lu -T +^ <br /> w� REGIONAL BOARD <br /> a /PHONE <br /> w (�) NAME ` <br /> Z 0 QUANTITY LOST(GALLONS) <br /> v>Oy (2) UNKNOWN �r <br /> m <br /> N Z t <br /> UNKNOWN I <br /> z DATE DISCOVERED 7. /��7 HOW DISCOVEAEO ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITK)NS <br /> w '-"b��r�✓r ❑ TANK TEST ❑ TANK REMOVAL OTHER (� <br /> m OATS DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) V <br /> 4 <br /> o M o r UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK d REMOVE �EPAIR PIPING <br /> Lu <br /> 0 HAS DIS ARGE BEEN STOPPED? REPAIR TANK <br /> OU CLOSE TANK d FILL IN PLACE ❑CHANGE PROCEDURE <br /> O YES ❑ NO IF YES,DATE 'Al j o yj r ❑REPLACE TANK ❑ OTHER <br /> SOUR OF DISCHARGE CAUSE(S) <br /> LZI w <br /> )5AECK <br /> TANK LEAK UNKNOWN OVERFILL RUPTUREIFAILURE ❑ SPILL <br /> ti UPIPING LEAK OTHER CORROSION UNKNOWN ❑ OTHER <br /> N Lu ONE ONLY <br /> U�I ❑ UNDETERMINED ❑ SOIL ONLY 14GROUNDWATER ❑ DRINKING WATER •(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Z <br /> NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> cry LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) /CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE 6 DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> tSM BACK Fart OEIAtM <br /> a Z <br /> 0 CAP SITE(CO) EXCAVATE d TREAT(ET) ❑ PUMP a TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> 0 <br /> w� <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) OTHER(OT) <br /> k/e.Vt'aw (a ry*k <br /> o I eye 4,o-Nk-S ct6c Lt ev*-.. i Y\ l i --+4 rfe��l-�1 <br /> I t N i !� c+ <br /> HSC 05 MW <br />