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U3? <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> FOR LOCAL AGEPlCY?iiSE ONLY <br /> REPORT BEEN FILED? <br /> Q YES NO ❑ YES Q NO 1 HERESYCERTIFYTFIAT1,HAVE DiSTRlBi7TEDTHIS INFOfiMATIQFI ACCORDING TOTHE <br /> DISTR IBUTK)N SHOWN ON THEIN CTION SHEET 0 THE BACK PAGE OF;THIS FORME <br /> REPORT DATE CASE <br /> /�/ s - <br /> �rn 71 Y r .SIGNED <br /> r. .>-.. - DATE..:: <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> m <br /> s ,4� <br /> w REPRESENTING Cl OWNER/OPSRATOR Cy REGIONAL BOARD . COMPANY OR AGENCY NAME i <br /> r <br /> cr <br /> LOCAL AGENCY ❑ OTHER �N V f I <br /> ¢ ADDRESS <br /> P0 , LOS $TREAT Gm 1 S§11rr E <br /> J NAME CONTACT PERSON PHONE <br /> x �* �~ <br /> z Q. ❑UNKNOWN <br /> a< ADDRESS //�_// /{/�J• /�/}�/�///� //�/��7 4 <br /> y rO STREET 'V • GRY J <br /> cr <br /> STATE [//() � /J <br /> FACILITY NAME(IF APPLICABLE) OPE TOR If PHONE a <br /> e a d /?a QjZ--.!Fz ,3 <br /> ADDRESS <br /> O <br /> y CROSS STREET <br /> U <br /> p LOCAL AGENCY AGENCY NAME CONTACT PERSON, PHONE <br /> z <br /> =W _ <br /> W C.] <br /> L ww7 REGIONAL BOARD PHONE <br /> Q w /%.- � l6) d 0 0 <br /> 1 <br /> NAME QUANTITY LOST(GALLONS) <br /> m () <br /> LU <br /> Z w A/P/r/L �`'W `� l�S ❑ UNKNOWN <br /> Z J y� <br /> co Z "' <br /> a UNKNOWN <br /> DA DISCOV D HOW DISCOVERED <br /> x INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> uj <br /> :z TANK TEST TANK REMOVAL ❑ OTHER <br /> M 93 Y ❑ <br /> e DATE DIACHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w Mr Y. ❑ UNKNOWN EMOVE CONTENTS E:]CLOSE TANK&REMOV£ ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> `nYES NO IFYES,DATE <br /> ❑ ❑ o r Y 'WEPLACE TANK �THER .... <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> yam=+ <br /> ¢ ❑ TANK LEAK UNKNOWN OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> 8 a <br /> U ❑ PIPING LEAK OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w ❑ NO ACTION TAKEN —] PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> m <br /> y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> 0 ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION{S} <br /> I>�eu�airanoeiiusl ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATKIN(IT) <br /> � <br /> a Z <br /> wo ❑ CAP SITE(CD) EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> aa ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REOUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) <br /> s ✓z <br /> w e5s e, <br /> /we, = de r .nom <br /> a � G <br /> HSC GSid" <br /> x <br />