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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY <br /> YES NO HASSTYES ATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY j. I <br /> REP <br /> ORT BEEN FILED? E>] I HEREBY CERTIFYTHATI HAVE DISTRIBUTED THIS INFORMATION ACCORDING TOTHE <br /> ❑ ❑ NO <br /> DISTRIBUTION SHOWN ON THE NSTRUCTION SHEET ON THE RACK PAGE OF THIS FORM <br /> REPORT DATE CASE a(]N '!y U D y SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> ( <br /> REPRESENTING ❑ OWNER/OPERATOR ❑ REGWNALSOARD COMPANY OR AGENCY NAME <br /> ILI <br /> S LOCAL AGENCY ❑ OTHER <br /> ADDRESS //`,gyp//,{,� /((�C <br /> \%/ STATE J z0 21� <br /> J <br /> NAME ,� CONTACTPERSON PHONE <br /> a V\(t Vo U\ - Ivy-C.O T S UNKNOWN if S B-USSe Ae ) <br /> w¢a <br /> ADDRESS I`fa-A STREET V,-C l V�'` CRr / / STATE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o i ;v A UA ` <br /> a <br /> ADDRESS <br /> y C`1ROSS STREET <br /> il�GC f� <br /> O "LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> Z N ) <br /> F l <br /> W <br /> w w REGIONAL BOARD PHONE <br /> f <br /> m (t) NAME OUAANN/T�ITY LOST(GALLONS) <br /> W O + CV <br /> Q J �. X _/ I l ❑ UNKNOWN <br /> U <br /> m i R) <br /> y— ❑ UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED E] INVENTORY CONTROL ❑ SUBSURFACE MONITORING E] NUISANCE CONDITIONS <br /> i <br /> Ou M D o o )r C' r ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK d FILL IN PLACE [:]CHANGE PROCEDURE <br /> % YES ❑ NO IF YES.DATE u u orCAUSE(S) <br /> y [:]REPLACE TANK ❑ OTHER <br /> iD SOURCE OF DISCHARGE <br /> TANK LEAK F—] UNKNOWN OVERFILL RUPTURE/FAILURE EDSPILL <br /> wo <br /> o ❑ PIPING LEAK F-1OTHER CORROSION ❑ UNKNOWN ❑ OTHER <br /> ww CHECK ONE ONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> W Z ❑ NOACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> aF LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> O rn ❑ 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 /> IffE wxraRoerue/ <br /> a i PUMP d TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> O 4 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ <br /> w rVENT SOIL(VS) <br /> wa CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED INA) ❑ TREATMENT AT HOOKUP(HU) <br /> ¢ ❑ VACUUM EXTRACT(VE) OTHER(OT) <br /> SI {e � re.4 +v L, c, ( Uv .rsly!�+ Fro Jra 5 � 4 for . <br /> � Irec ( /v� 5 on �urf!^rf tnj"5�`i� a� <c61 . <br /> s J <br /> 8 <br /> Nsc os loam <br />