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UNDERGROUND STORAGE TAO(UST) SITE - UNAUTHORIZED RELEASE-KONTAMINATION REPORT <br />EMERG NC Y HAS STATE OFFICE OF EMERGENCY E VICES <br />REPORT BEEN FILED? ❑ Yes o <br />FOR LOCAL AGENCY USE ONLY <br />1 HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br />❑ YesNo <br />REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br />THE HEAL SAFETY COD . <br />REPORT IIATE <br />CASE # <br />Vl ✓ (3 <br />SIGNE DAT <br />NAME NDIVIDUAL FILI G REPORT <br />PHONE <br />SIGN <br />E <br />mCOMP <br />❑ <br />RES NI <br />OCAL AGENCY El REGIONAL BOARD <br />NY OR AGENCY RME <br />r <br />, <br />(n V <br />t <br />0 <br />OWNER/OPERATOR ❑ OTHER <br />u <br />ADDRESS <br />WETCITY STATE ZIP' <br />Li <br />-j <br />E0 <br />AME r CONTACT ERSON PHONE <br />f ' 0 ❑ Unknown <br />p m <br />IL c <br />ADDRESSLLI <br />`' -a STREET ✓ 1/" '—Y r CITY l STAT ZIP �� <br />z <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />(PHONE <br />0 <br />P <br />o <br />ADDRESS , 1 <br />LU <br />l STREET ✓� CITY C0UNTY�4� ZIP <br />CROSS STREET <br />6 L b1 V� <br />0 <br />z�� <br />LOCALAGENCY AGENCY NAME 10 <br />44 �" �ir` �`� rV1 <br />PHONE <br />Z U <br />wLL, <br />2 <br />l l�'W� l/V `�� IV1r <br />REGIONAL BOARDn <br />69 <br />PHONE <br />coo"QUANTITY LOST (GALLONS) <br />NAME <br />Lu <br />U w <br />Z <br />-/njamn �p/�r ( <br />lTyl� "'l "17 l,t�l �/ 1600 I Unknown <br />Q 0 <br />In M O <br />? <br />(�) <br />❑ Unknown <br />z <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ Tank Test ank Removal ❑ Nuisance Conditions <br />Uj <br />w <br />D <br />❑Inventory Control Subsurface Monitoring Other / <br />DATE DISCHARGE E AN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />❑ Remove Contents ❑ Close Tank <br />U1 <br />Unknown <br />❑ Repair Tank El Change Procedure <br />HAS DISCHARGE BEEN STOPPED? <br />0 <br />❑ Replace Tank Other/) �pji/vL 6VA <br />Zt <br />zk(es ❑ No IF YES, DATE �� l 7J" <br />❑ Repair Piping <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />Uy <br />D a <br />o <br />�Jank ❑ Piping ❑ Dispenser ❑ Delivery Problem <br />(]_Submersible Turbine Pump (STP) [1 Other <br />❑ Spill ❑ Overfill Physical/Mechanical Damage ❑ Corrosion <br />E-1 Installation Problem Unknown they S� <br />ww <br />CHECK ONE ONLY <br />�a <br />❑ Undetermined XSoil Only ❑ Groundwater ❑ Drinking Water — (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />ueMOpen <br />,HECK ONE ONLY <br />- Site Assessment ❑ Open -Verification Monitoring <br />c Q <br />D " <br />❑ Open - Assessment & Interim Remedial Action ❑ Open - Inactive <br />Q Open - Remediation ❑ Closed — No Further Action Required <br />U <br />CHECK APPROPRIATE ACTION(S) <br />MUnknown <br />0 <br />Human health exposure control? ❑ Yes ❑ No <br />P: <br />Groundwater migration control? ❑ Yes ❑ No nknown <br />a <br />0 <br />LU <br />ElNo Action Required (NAR) [:1Excavate & Treat (ET)❑Treatment at Hookup (TH) ❑Other <br />❑ Excavate & Dispose (ED) ❑ Free Product Removal (FPR) ❑ Replace Supply (R <br />w <br />U" q�offfvj <br />Z — 4, �;ofe <br />--------.,�____, Rev- nzmtn_ot2 <br />SWRCB Leak Report Form 11ttp:iiwww.swrco.Cu.guvIva tv,_ —.,. p urpa ••� �• •- <br />