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{ <br /> - i <br /> I <br /> C �� • Lu'o <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL'AGENCY;:USE'ONLY <br /> REPORT BEEN FILED 7 <br /> ❑ YES NO ❑ YES ❑ NO :.I HEREBY,CERTIFYTHAT l I IAVE.01STRIBUTEO THIS INFORMATION ACCORDING TO THE <br /> :,01MIBUTION SHOWN ON.THE.INSTRIJCTION SHEE.r:ON THE BACK PAGE OF THIS,FORW. <br /> REPOR/T`DDATE CASE s <br /> M `�MI 1 Y <br /> SIGNED_ BATE <br /> NAME <br /> OF,INDIVIDUAL FILING REPORT PHONE {� �J SIGNATURE <br /> m �r f r Cts j3fO% r S �`�.l)It bJ 3*is, J <br /> w REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> LOCALAGENCY ❑ OTHER <br /> ADDRESS A <br /> I � q <br /> STREET CRY $TATE ZIP <br /> Lu NAME CONTACTPERSON /PHONE <br /> ca <br /> ? ❑ UNKNOWN G- {amu I p/A } <br /> f'g�� 3 <br /> Oa ADDRESS <br /> Lo <br /> w la la C �-C3�%�a f?f�, Box' J o *9 V S-fo 6-P tl-w C14 9 5'R 13 <br /> t <br /> sTRE cm STATE P <br /> a <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE r <br /> a ADDRESS/ �^, <br /> I U ` <br /> w STREET CTfY COVNTV ZIP 1 <br /> w <br /> CROSS STREET 1 <br /> O LOCALAGENCY V AGENCY NAME CONTACTPERSON PHONE ` <br /> z wLu <br /> If <br /> Lu <br /> Lu M REGIONAL BOARD v PHONE <br /> CL <br /> (a (1) NAME QUANTITY LOST(GALLONS) y <br /> w I <br /> Z j G L � �' UNKNOWN <br /> a J <br /> m z (�) <br /> wI ❑ <br /> UNKNOWN <br /> z GATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITOR WG ❑ NUISANCE CONDITIONS <br /> �7 TANK TEST TANK REMOVAL YTyOTHER <br /> MI oMI -RDI 6p Y75Y ❑ L7e- <br /> )L <br /> -y� <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> m M M p Y y UNKNOWN REMOVE CONTENTS OSE TANK b REMOVE ❑REPAIR PIPING <br /> Lu t <br /> 0 /� <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK 6 FILL IN PLACE ❑CHANGE PROCEDURE <br /> YES ❑ NO IF YES,DATE (f 1 ❑REPLACE TANK E:] OTHER <br /> U M J p Ad Y Y <br /> SOURCE OF DISCHARGE \ CAUSE(S) [� 1 <br /> ja ❑ TANKLEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> N U ❑ PIPING LEAK F--j OTHER ❑ CORROSION UNKNOWN ❑ OTHER L•7a' <br /> y wCL CHECK ONE ONLY <br /> O ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK <br /> ONE ONLY 1J�� <br /> w IX! NO ACTION TAKEN F-1PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> jH � LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY E] POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE S DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑' ENHANCED BIO DEGRADATION(IT) <br /> 15a a Fon MT•• <br /> n o ❑ CAP SITE(CD) 'EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) f <br /> L) ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOtL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> HSC 05(ergo) <br />