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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 /> REPORT BEEN FILED 7 YES YES NO D 1 HEREBY CERTIFYTHAT t_HAVE DISTRIBU THIS INFORMATION ACCORDING TO THE <br /> ❑ ❑ ❑ <br /> DISTRIBUTION SHOWN ON:THE INSTRUCT SMfEET.ONTHE K PAGE OF.THIS FORM::<:` <br /> REPORT DATE� CASE s <br /> Intl �I Vd oI v SIGNED.:: DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> C3 REPRESENTING F-1 OWNER/OPERATOR REGIONAL BOARD COMPANY OR AGENCY NAME J� <br /> pLOCAL AGENCY ❑ OTHER �ffS'/�/ �1/N ► r J--> <br /> ADDRESS //�� J�� �� ] <br /> i Z �/ saf€E� cm /v!�f Sr1TE ! nP� <br /> w NAME CONTACT'(P'ERSON t PHONE Q J <br /> z �� 6 >�r 6 T P UNKNOWN <br /> O< ADDRESS <br /> w <br /> x -3L7V S fzthg=b1 cm / STATE 1_ <br /> FACILITY NAME(IF APPLICABLE) OPERATOR J PHONE <br /> o I� b L4 r 7�-N( P�� t ) <br /> < ADDRESS <br /> w !/ � 1?,/ STREET <br /> ✓. �Y i I-..t �� �� l COUNTY • `� IP <br /> O <br /> w <br /> CROSS STREET <br /> O <br /> LOCAL <br /> 1AAt tNCY , / 4/ AGENCY NAME CONTACT PERSON PHONE <br /> Am <br /> w l REGIONAL BOARD PHONE <br /> U) (1) NAME QUANTITY LOST(GALLONS) <br /> 0 <br /> <w Oi l e 1sv� VI 1 © �' /�' O ❑ UNKNOWN <br /> j z (2) <br /> `� ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w MI MI oI oI I ylLu <br /> r [:] TANK TEST TANK REMOVAL ❑ OTHER <br /> <m DATE DISCHARGE BEGAN METHOD USED TO STOP D�ISCHARE(CHECK ALL THAT APPLY) <br /> <cc <br /> UNKNOWN ❑REMOVE CONTENTOSE TANK&REMOVE ❑REPAIR PIPING <br /> w M M D 0 Y Y <br /> p HAS DISCHARGE BEEN STOPPED Z ❑REPAIR TANK E]CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> YES NO IF YES,DATE r REPLACE TANK OTHER <br /> � M� M� D� of v ❑ <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> D a TANK LEAK UNKNOWN OVERFILL RUPTUREIFAILURE ❑ SPILL <br /> y v ❑ PIPING LEAK OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> v ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w <br /> c y ❑ LEAK BEING CONFIRMED f PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAYC <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J (SEE BAC9 FM CETNS) <br /> <_z <br /> ❑ CAP SITE(CO) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)a REPLACE SUPPLY(RS) <br /> L O <br /> w< <br /> Lu <br /> F--] CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) a VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHE (O� <br /> cn <br /> w <br /> vtee,��►n �r� thy- v�u µ.-ms a�-�Q /� �� ,J <br /> HSC 05(&W <br />