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..W/ l'- U09 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL'AGENCY USE ONLY <br /> YES NO <br /> REPORT BEEN FILED 9 YES l HEREBY CERTIFY THAT f.HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> 0 O <br /> DISTRIBUT SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF TyIS FORM <br /> REPORT DATE CASES <br /> J M MI I DATE. /. ' . <br /> NAME OF INDIVIDUAL FILING REPORT PHONE Qd�' SIGNASRE <br /> m <br /> �2-�G '-7'�v� (•�,)CGS-3���� � _-,, -_ <br /> REPRESENTING O OWNER/OPERATOR REGIONAL BOARD COMPANY OR AGENCY NAME <br /> pLOCAL AGENCY OTHERui <br /> tr AD RESS C4- <br /> �C"I C _ GL'r ij � ✓�✓ _ :Y��+�r'LC �, ) :�c�/�%C� �/ % <br /> STREET CITY STATE ZIP <br /> Lu NAME CONTACTPERSON PHONE <br /> Z .4 fAUNKNOWN % �O'V'f / �� ��•�%) ��3- GvZs <br /> a a ADDRESS <br /> CLcr 1,51 w <br /> STREET CITY STATE ZIP <br /> FACILITY <br /> gE(IF APPLICABLE) OPERATOR (PHONE <br /> UADDRESS <br /> w STREET CITY COUNTY 21P <br /> N <br /> CROSS STREET <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w w REGIONAL BOARD PHONE <br /> J< <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> w <br /> o �� �!✓ UNKNOWN <br /> a <br /> F <br /> U)> (Z) <br /> �z <br /> cn 0 <br /> UNKNOWN <br /> z DATE DISCOVERED �i HOW DISCOVERED � INVENTORY CONTROL SUBSURFACE MONITORING a NUISANCE CONDITIONS <br /> w `� MI %MI /,1 l o1 v v TANK TEST TANK REMOVAL OTHER <br /> a <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> > NKNOWN REMOVE CONTENTS CLOSE TANK&REMOVE REPAIR PIPING <br /> cc <br /> M M o D r r <br /> p HAS DISCHARGE BEEN STOPPED 7 F7REPAIR TANK Q CLOSE TANK&FILL IN PLACE E:]CHANGE PROCEDURE <br /> U <br /> YES O NO IF YES,DATEM MI D V Y O REPLACE TANK OTHER <br /> O � <br /> LD <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> Lu <br /> F TANK LEAK UNKNOWN OVERFILL RUPTURE/FAILURE SPILL <br /> ON O 0 PIPING LEAK OTHER CORROSION UNKNOWN O OTHER <br /> w w CHECK ONE ONLY <br /> 0 a <br /> O UNDETERMINED a SOIL ONLY O GROUNDWATER = DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHtCK ONE ONLY <br /> Iz a NO ACTION TAKEN a PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED O POLLUTION CHARACTERIZATION <br /> cr O LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> U) <br /> U O REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) a EXCAVATE&DISPOSE(ED) 0 REMOVE FREE PRODUCT(FP) a ENHANCED BIO DEGRADATION(IT) <br /> J (SEE BACK TOR DEfAIS) <br /> o p 0 CAP SITE(CD) EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> w� <br /> Lu a F-] CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) a VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) a OTHER(OT) <br /> sO/G ,�-<%SfJ�'cj- r`�'`�'`� �/i .� --�Zi✓tel G T- D/Cel-,� S'o�L- Gam.� r /�l/ ' /�� � .�'i�i1 <br /> z 5 r C -- ` -r4` <br /> Lu a <br /> U <br /> HSC 05(850) <br />