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yo)- � L / <br /> 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 1 HEREBY CERTIFY THAT i HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ YES NO ❑ YES NO <br /> DISTAL�UTIONHOWN ON THE 1 UCTION SHEET ON THE 13ACK PAG OF THIS ORM. <br /> REPORT DATE CASES f „ 7 3 <br /> tj <br /> M M14 SIGNORTE GY <br /> NAME�F INDIVI UAL FILING REPORT PHONE SIGNARE <br /> m <br /> Linda q <br /> w REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPA[YRAGENNN AME ,, <br /> cc <br /> OCAL AGENCY ❑ OTHER �Ut�ti, fkawx w <br /> Fr <br /> A,p(92r=SS 1 �2J/� /d �-7•��1.r / III 611 1 y"V R iIY� CITY ih �� 1 STATE <br /> ZIP <br /> J NAME CONTACTPERSON PHONE <br /> cn <br /> z l,� ma �-n <br /> -] UNKNOWN <br /> oaa ADDRESS <br /> LLJ <br /> N a &F" <br /> Q P-Q STREA PlfC)rCf (-4 9C'11]�(3 _�X5 y i LSTA� ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> z <br /> 0 <br /> U ADDRESS `ML �' SIT. <br /> TCj)p c)�CCOU <br /> ZIPw <br /> CROSS STREET <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w U <br /> w owin <br /> wa REGIONAL BOARD PHONE <br /> (L 1 <br /> NAME QUANTITY LOST(GALLONS) <br /> W p <br /> Z j ( UNKNOWN p <br /> m (2) <br /> Z_ <br /> U) ❑ UNKNOWN ((1 <br /> Z DATE DISCOVERED l/r�� HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS \ <br /> z (),Al12_ <br /> V v- v ❑ TANK TEST ❑ TANK REMOVAL OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> a <br /> > UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE D REPAIR PIPING <br /> M M D D Y Y <br /> > <br /> 0 HAS DIS ARGE BEEN STOPPED 7 REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> YES ❑ NO IF YES,DATE . <br /> MI D V Y E:]REPLACE TANK E::] OTHER <br /> D <br /> SOUR OF DISCHARGE CAUSE(S) <br /> o Cc w <br /> 5 TANK LEAK ❑ UNKNOWN ❑ OVERFILLRUPTURE/FAILURE ❑ SPILL <br /> U)0 PIPING LEAK ❑ OTHER F-] CORROSION ❑ UNKNOWN ❑ OTHER <br /> N nw ECK 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 F7 PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> 0 a ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ./CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> J (SEE BACK FOR DUALS) <br /> o p ❑ CAP SITE(CD) F—] EXCAVATE 8 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> cr 3K VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> En <br /> w Itie -5 c lunv _ i l <br /> "V <br /> HSC 05(950) <br />