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UNDERGROUND STORAGE TANK(UST)SITE - UNAUTHORIZED RELEASE I CONTAMINATION REPORT <br /> EMERGEN Y HAS STATE OFFICE OF EMERGENCY_ SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑Yes o REPORT BEEN FILED? []Yes �No I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORT DATE REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> CASE# T. HEALiH;- .O;AU� <br /> NAME OF INDIVIDUAL FILING REPORT PHONE e v yr l UKt <br /> coEPRESENTIN <br /> p COMPANY OR AGENCY NAME <br /> F OCAL AGENCY ❑ REGIONAL BOARD <br /> p ❑OWNER/OPERATOR <br /> [:1 OTHER <br /> ADDRESS <br /> �j cJ\`�/ C,l 1 C K/'-�,�`r��'►�/� �} <br /> �' ! - -- <br /> STR'JT/ -1 CITYSTATE <br /> ZIP <br /> J NAME 1 /1 �� �n J CONTACT PERSON PHONE <br /> F �.�J Cor{"! �r�I( lfU�� ❑Unknown <br /> Z,a ADDRESS <br /> LOLJ <br /> Ir <br /> STREET <br /> CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) --7 OPERATOR PHONE <br /> a <br /> ADDRESS r <br /> IL <br /> w ! / / v STREET CITY COUNTY �ry ZIP <br /> LO CROSSSTREET <br /> rr <br /> LOCAL AGE AGENCY NAME PHONE <br /> zw <br /> w � 2 W,? �'v 07 v7\,( � ( J) f-3�f2G7 <br /> az <br /> ¢ REGIONAL BOARD PHONE <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> wp <br /> Z <br /> jUnknown <br /> m° (Z) <br /> �Z <br /> ❑ Unknown <br /> DATE PISCO ERED HOW DISCOVERED <br /> W �y ❑Tank Test Tank Removal ❑Nuisance Conditions <br /> ✓ �Z �4� ❑ <br /> Inventory w ry Control ❑Subsurface Monitoring ❑Other <br /> M <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> y Remove Contents ❑ Close Tank <br /> U> 14nknown ❑Repair Tank ❑ Change Procedure <br /> O HAS DISCHARGE BEEN STOPPED? —/—� <br /> N ❑ Replace Tank Other �YL <br /> o ❑Yes ❑ No IF YES,DATE (),r) le�n D LLD 1 ) ❑ Repair Piping <br /> Lw SOURCE OF DISCHARGE CAUSE(S) <br /> Uy <br /> K <br /> z)¢ ❑Tank ❑Piping ❑Dispenser ❑Delivery Proble El Spill El Overfill Physical/Mechanical Damage El Corrosion <br /> UO)0 ❑Submersible Turbine Pump(STP) _Other j I (jf�( '/ ❑Installation Problem AUnknown ❑Other <br /> CHECK ONE ONLY <br /> W <br /> a <br /> U� X}Indetermined ❑Soil Only ❑Groundwater []Drinking Water—(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> ° C]Open- Assessment OSite At <br /> w C1 Open- Verification Monitoring <br /> U El Open-Remediation <br /> C]Open-Assessment <br /> &Interim Remedial Action osed NoInactiveEl CFurther Action Required <br /> z CHECK APPROPRIATEACTION(S) <br /> o Human health exposure control? ❑Yes ❑No ❑Unknown <br /> Groundwater migration control? ❑Yes ❑No ❑Unknown <br /> a ❑No Action Required(NAR) ❑Excavate&Treat(ET) ❑Treatment at Hookup(TH) ❑Other <br /> 0 <br /> w ❑Excavate&Dispose(ED) ❑Free Product Removal(FPR) ❑Replace Supply(RS) <br /> w <br /> V) <br /> z <br /> z <br /> w <br /> 0 <br /> O <br /> U <br /> SIVRCB Leak Report Form httn://ivNvw.sivreb.ca.gov/water issues/nroerams/ust/forms/ Rev_02/01/2012 <br />