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9,2 <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 No YE <br /> ❑ YES s O ;i HEREHYCERT)FYTHAT 1.-,HAVE DISTRIEUTED.. 15)MFDRMATIONACCORDING,TOTHE <br /> ❑ OISTHIBUTICNSHOVlNONTH U EFONTHEBACK.PAGEOFTHISFORM% <br /> REPORT DATE CASE(1 <br /> NAME OF INDIVIDUAL FILING REPORT - PHONE SIGNATURE <br /> y�at�l iZo9 )y6p-o33/ <br /> REPRESENTING ❑ OWNER(OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> CL <br /> LOCAL AGENCY [:] OTHER <br /> � ADDRESS <br /> 1 .� / l �7 <br /> [ 1 141' s J e> vr- CITY / STATE <br /> Lu ZIP <br /> NAME CONTACT PERSON PHONE <br /> m <br /> Yr 4e-C UNKNOWN5 ) <br /> 1 <br /> (L as ADDRESS <br /> L <br /> 4 / STREET C'c �� WRY <br /> . <br /> STATE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> a ADDRESS <br /> U <br /> O <br /> WZ`zSTREET a 1 � 36 <br /> y © coum" J 9s 3COSS STREET <br /> zip <br /> c`I <br /> c_7 LOCAL AGENCY AGENCY NAME <br /> z rn CONTACTPERSON <br /> F ca w 2�-��1 PHONE <br /> W S•t 1 oa v n - <br /> UUj w REGIONAL BOARD <br /> aC V r/]I ) � C--2) <br /> � PHONE <br /> y (1) <l ✓ NAME <br /> 4 w S d /, �' QUANTITY LOST(GALLONS) <br /> O (2) ❑ UNKNOWN <br /> mZ <br /> ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL w �j I ❑ ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w 0� /M W 60 �, Y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> r- � <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CH CK ALL THAT APPLY) <br /> a <br /> } NKNOWN ❑REMOVE CONTENTSREPAIR PIPING <br /> GLOSE TANK S REMOVE <br /> ❑ <br /> p HAS DISCHARGE BEEN STOPPED 7 REPAIR TANK <br /> U E] ❑CLOSE TANK a FILL IN PLACE ❑CHANGE PROCEDURE <br /> YES ❑ NO IFYES.DATE !..f <br /> � al 71 � ! d�Y ❑REPLACE TANK ❑OTHER <br /> Y <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> Z)w <br /> a ❑ TANK LEAK UNKNOWN ❑ OVERFILL RUPTURE/FAILURE ❑ SPILL <br /> H C7 ❑ PIPING LEAK ❑ OTHER ❑ CORROSIONNKNOWN ❑ OTHER <br /> w w CHECK ONE 0 LY <br /> v UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER CHECK ONE ONLY WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> i <br /> h i <br /> cc <br /> U ❑ NO ACTON TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> �� ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY <br /> v ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDL4TION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTIONS) EXCAVATE&DISPOSE E <br /> a r�e�craROETn.sl ❑ ( D) REMOVE FP <br /> ❑ ( ) ❑ ENHANCED BIO pEGRADATION(IT) <br /> w o ❑ CAP SITE(CD) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP 8 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Lu <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> �r���i S'•I QSScSS��� 4�i/ .��/ ri c/crosS�ry � !, <br /> 114;-1,7/�� Ic� �X7`�✓!71- <br /> HSC 05("m <br />