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-'7l <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? VI HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> YES ❑ NO YES ❑ NO <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM: <br /> REPORT DATE CASEV^y <br /> �u� ✓u� �d a� r <br /> NAME OF INDIVIDUAL FILING REL94T PHONE I SIGNATURE <br /> >- '/-6�r-3 qjb , <br /> REP G E H <br /> COMPANY OR AGENCY NAME <br /> w ❑ OWNER/OPERATOR REGIONAL BOARD <br /> ❑ <br /> Q LOCAL AGENCY ❑ OTHER <br /> � <br /> a �^ / ��// //y►. <br /> 2 ADDRE$� O' /� ^ �D 7 \ foc /��Le _ C/ 1 �5� O ' <br /> "��1�( �T(aJeEr // v '(] I\ Tc(1" STATE ZIP <br /> w <br /> NAME PERSON PERSON PHONE <br /> z MC O &�cb Lo v K ❑ ( 1 <br /> UNKNOWN <br /> z� <br /> O¢(L CL ADDRESS <br /> 351 G CITY STATE P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS <br /> ONtw J ! CITY COUNTY ZIP <br /> w <br /> N I CA-OSS STREET <br /> Gh e-r o <br /> O LOCAL AGENCY AGENCY NAME CONTACTPERSON /� I PHONE!� �� <br /> w <br /> wo <br /> w w REGIONAL BOA RQ PHONE <br /> CL13 <br /> Iw' <br /> N (�) NAME QUANTITY LOST(GALLONS) � <br /> w O ❑`,'`tee <br /> U w UNKNOWN <br /> Z <br /> ¢ 0 `y <br /> U Z (2) V <br /> co <br /> U) - ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL El MONITQRIIN�G ❑ NUISANCE CONDITIONS <br /> Lu ,4'\❑ TANK TEST ❑ TANK REMOVAL OTHER <br /> Lu a, lM�r t(�1 <br /> ON� 5u� I D� �r r <br /> ¢co DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT AP LY) <br /> i ❑ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> M D Y Y <br /> p HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK S�FILL IN PLACE ❑CHANGE PROCEDURE <br /> REPLACE TANK OTHER <br /> C YES ❑ NO IF YES,DATE M uI DI ri Y ❑ <br /> S URC OF DISCHARGE CAUSE(S) <br /> a ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE SPILL <br /> U)v ❑ PIPING LEAK OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> u SOIL ONLY ❑ GROUNDWATER [:] DRINKING WATER •(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> 1:1 UNDETERMINED <br /> CHECK ONE ONLY <br /> w ❑ NO ACTION TAKEN F7 PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> cc <br /> N ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> J ISEE LACK FOR DETA&SI <br /> a z F7PUMP d TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> CAP SITE(CD) EXCAVATE b TREAT(ET) ❑ <br /> OU F7 CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) F7TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ¢ <br /> w¢ <br /> ❑ <br /> VACUUM EXTRACTIVE) ❑ OTHER(OT) <br /> � • <br /> Z � 14�� um � pCj(.a <br /> o <br /> U <br /> HSC 05(aW <br />