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- Lk :? <br /> UNDERGR UND STORAGE TANK UNAUTHOR ED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVI S FOR L AGENCY USE ONLY <br /> El REPORT BEEN FILED 7 1 HE BY C FYTHAT I HAVE IS IBUTEDTHIS INFORMATION ACCORDING TO THE <br /> YES NO ❑ YES NO <br /> DIS RIBUT OWN ON TH U N THE BACK PAGE F HIS FOR <br /> (REE�!P�ORT ATE Q/ CASES <br /> //////. � . <br /> L�M 1/ M <br /> NAME DIVIDUAL FILING PORT PHONE SIGNA RE <br /> FILING <br /> m y(��D <br /> w REPRE NTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> Er LOCAL AGENCY ❑ OTHER S <br /> ¢ ADDRESS <br /> L/ N� � .�aa .- CITY CAE 9szc� <br /> ZIP <br /> ca J <br /> 17E CO� PHONE <br /> / ACTPERSON <br /> im ❑ UNKNOWN L�c <br /> z <br /> a as AD RE�SS <br /> cn <br /> Lu <br /> �iz fbar 55t6ie/�)j CA 95Zo9 <br /> FACI ITYNAME(IF APPLICABLE) OPEgATOR PHONE <br /> kkl6-f g <br /> 0 <br /> A Eqq �M��� V� S JNn qzo 5 <br /> H ZIP <br /> F, CROS TREET <br /> n 10, <br /> O LOC GE Y' AGENCY NAME CONTACT PERSON PHONE <br /> z W <br /> W O <br /> w w REGI AL BOARD PHONE <br /> U) (1) NAME QUANTITY LOST;tN?WN <br /> el/[.w <br /> M o (Z) <br /> UNKNOWN <br /> kA <br /> Z DATE Yl ,)VERED q HOW DISCOVERED ❑ VENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> wMII DI /v j <br /> ❑ TANK T TANK REMOVAL ❑ OTHER <br /> am DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHA E(CHECK ALL THAT APPLY) <br /> m <br /> UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> 2 M M D D Y Y <br /> W <br /> p HAS DI HARGE BEEN STOPPED 7 ❑REPAIR TANK O CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> 0 YES ❑ NO IF YES,DATE .1 <br /> I J F-]REPLACE TANK a OTHER <br /> D D Y Y <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> 5 ❑ TANK LEAK UNKNOWN ❑ OVERFILL UPTURE/FAILURE ❑ SPILL <br /> ti O ❑ PI ING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> Ly w CHECK NE 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 /> Q <br /> D I ❑ 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 BIO DEGRADATION(IT) <br /> J (SEE BACK FOR DETAlS) <br /> az <br /> 0 O F-1CAP SITE(CD) F-] EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w� <br /> w0 [:] CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) F-] TREATMENTAT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> cr ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> �111i}�S/ u SSS /dui GU t / 72 7) <br /> WlAe— <br /> HSC 05(850) <br />