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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES .FOR,LOCAC`hGENCY:USE ONLY:; <br /> REPORT BEEN FILED 7 <br /> YES No Q YEs NO 1 HEREBY CERTIFYTHAT 1;HAVE DIST..RIBUTED THIS INFORMATION ACCORDING TOT <br /> DISTRIBUTION SHOWN ON THE WSTRUCTION SHEET ON THE BACKPAGE Of THIS FORM. <br /> REPORT <br /> �DATE1 CASEa <br /> 0 M ` M \ �Y SIGNED <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIG RE <br /> ( ) (p�,�ggm J" <br /> w Rcr <br /> EPRESE TING 0 OWNER/OPERATOR � REGIONAL BOARD COMPANY OR AGENCY NAME <br /> :OCAL AGENCY Q OTHER �t Q ei U ('(.0 <br /> ¢ ADDRESS <br /> a q - wAE< STATE ZIP <br /> w NAME CONTACT PERSON PHONE <br /> J <br /> z O UNKNOWN ) <br /> O a ADDRESS <br /> cow <br /> cr <br /> STREET CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> 0 ch <br /> a ADDRESS <br /> F ..AA,\\ cl i <br /> w <br /> lJ'e.� CITY COUNTY IP <br /> n-i CRaSTREET lk— <br /> LOCAL AGENCY AGENCY NAME CO TACT PERS9N T PHONE ` <br /> OQ/ <br /> z <br /> (d K„ ( tm ) <br /> w w REGIONAL BOAR PHONE <br /> CLs <br /> In NAME QUANTITY LOST(GALLONS) <br /> U w UNKNOWN <br /> z <br /> a� <br /> m o (2) <br /> ti a UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED Q INVENTORY CONTROL O SUBSURFACE MONITORING Q NUISANCE CONDITIONS <br /> Z <br /> w OTANK TEST �gTANK REMOVAL Q OTHER <br /> Ic DATE DISCHARGE BEGAN Y Y METHOD USED TO STOP DISCHARG HECK ALL THAT APPLY) <br /> a <br /> UNKNOWN Q REMOVE CONTENTS CLOSE TANK 6 REMOVE REPAIR PIPING <br /> HAS DISC M RGE BEEN STOPPED?01 yl Y O REPAIR TANK Q CLOSE TANK&FILL IN PLACE [�]CHANGE PROCEDURE <br /> rn YES 0 NO IF YES,DATE �MI 0 3 v Y <br /> 0 YF <br /> 0 REPLACE TANK 0 OTHER <br /> SOURCE OF ISCHARGE CAUSE(S) <br /> ¢j TANK LEAK UNKNOWN 0 OVERFILL Q RUPTURE/FAIIURE Q SPILL <br /> Env PIPING LEAK Q OTHER 0 CORROSION NKNOWN 0 OTHER <br /> Lu w CHECK ONE ONLY <br /> Na <br /> v UNDETERMINED O SOIL ONLY GROUNDWATER E] DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z N 0 NO ACTION TAKEN F-1PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED O POLLUTION CHARACTERIZATION <br /> w <br /> ¢ LEAK BEING CONFIRMED F-� PRELIMINARY SITE ASSESSMENT UNDERWAY 0 POST CLEANUP MONITORING IN PROGRESS <br /> Dy <br /> O REMEDIATION PLAN a CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> � NS) F-1EXCAVATE&DISPOSE(ED) Q REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> Isran MALS) <br /> a z � CAPSITE(CD) Q EXCAVATE d TREAT(ET) PUMP&TREAT GROUNDWATER(GT)O REPLACE SUPPLY(RS) <br /> w 0 VENT SOIL(VS) <br /> w a E] CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) <br /> ¢ E] VACUUM EXTRACT(VE) O OTHER(OT) <br /> cn <br /> z <br /> Lu <br /> O <br /> U <br /> HSC 05(050) <br />