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�1 Z <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY <br /> REPORT BEEN FILED?❑ <br /> YES NO ES F7 NO <br /> 1 HEREBY CERTIFY THAT 1 HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE Y <br /> DISTRIBUTI SH N THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. <br /> REPORT DATE^[ 70J <br /> CASE aof 3 SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATU <br /> Lu REPRESENTING ❑ OWNER/OPERATOR REGIONAL BOARD COMPANY OR AGENCY NAM <br /> LOCAL AGENCY ❑ OTHER S' �� _En <br /> W <br /> Dia 5+®clfl&0_7� c <br /> STREET CRY STATE z)p <br /> w NAME CONNi6TACTT PERSON PHONE <br /> co <br /> z ❑ UNKNOWN L l Q/ ( L �3 — 116 P <br /> a a ADDRESS �//� / �/� /y♦ (/`J�c///�� /�}�[ (/� <br /> cc <br /> CL V� l� , 1 C'✓I �JTJ 7 S 1. � CIIY �V'/ — STA 1 V( D <br /> STREETZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ZSlit [D S � U IDS ( ) <br /> 0 <br /> < ADDRESS <br /> o <br /> wrC/n T/COw / ECSTl crry <br /> - <br /> COUNTY <br /> N CROSS STREET <br /> Let"r1� <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> Lu <br /> Lu w REGIONAL BOARD PHONE <br /> a-C7 <br /> w (1) NAME p ] QUANTITY LOST(GALLONS) <br /> Z w Ol-C/`� �^ �L�" ' .3 ( 1 1NKNOWN <br /> a J <br /> C13 O (Z) <br /> D? <br /> N ❑ UNKNOWN <br /> z <br /> �/DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> M1 M1 ✓ DI.3 DI Y17j ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> W M M D D Y Y <br /> 0 HAS DISCHARGE BEEN STOPPED? F-1REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> U) <br /> [:] YES ❑ NO IF YES,DATE 0.1 /Ml U D 3D 1(%�v !7 v ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGECAUSES) <br /> w <br /> cn ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> c O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> wwa CHECK ONE ONLY <br /> U ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w <br /> F__] NOACTIONTAKEN F__] PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> rt <br /> c F-1LEAK BEING CONFIRMED F__] PRELIMINARY SITE ASSESSMENT UNDERWAY [:jPOST CLEANUP MONITORING IN PROGRESS <br /> vcn <br /> ❑ 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 CETMS) <br /> a Z <br /> 0 F-1CAP SITE(CD) E:] EXCAVATE&TREAT(ET) E:] PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> 0 <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) GGT[ <br /> 1- ail <br /> 72_� AlYn,16,41 ami 07..� xi;b- pat"614-1 <br /> HSC 05(&W <br />