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LOU REPRESENTING ❑ LOCALAGENCY ❑ 2 cc ADDRESS Lu NAME J caa CC ADDRESS ya w Cc FACILITY NAME (IF APPLICABLq �\RC ADDRESS q6 yLo r ROSS STREET -V�J P \k�,,. 1 6`16 ,54ts4 JATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME W ❑ UNKNOWN STREET CONTACT stJR _ CITY wo Ca. 900a STATE w), ZIP PHONE t PHONE (20g)M2- (9 LOCAL AGENCY AGENCY NAME Q 5 ❑ CONTACT PERSON PHONE W PIPING LEAK ❑ OTHER Co FM w w �� c�eve.� czo�9) ae��- �la� MW ¢ ��. REGIONAL BOARD 'Rec> . w �a�v+vrs6s vmsl PHONE tq�tE, Hass- i3°t ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS s ❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 6 DISPOSE (ED) REMOVE FREE PRODUCT (FP) ElENHANCED BIODEGRADATION (IT) 0 0 WW w C (D�n\�, �\ NAME QUANTITY LOST (GALLONS) UNKNOWN Z V 5��e wrre. k% q rpvvt p �w� (�vST SvT�..'�.�rge��o�ic� tvnsv\�C�n �bu"J g►�sn FP q 61 ri�CotZ� v� �\ Q J m o (2) HSC 05 (a" y ❑ UNKNOWN DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE M NITORIN1G ❑ NUISANCE CONDITIONS z C1�I M `� \ oI v 5 v ❑ TANK TEST ❑ TANK REMOVAL ® OTHER �y� mDATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) UNKNOWN E]REMOVE CONTENTS ❑ CLOSE TANK & REMOVE REPAIR PIPING o Y ❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE E] CHANGE PROCEDURE HAS DISCHARGE BEEN STOPPED Z y W) vcs I—I un IE vFs_ DATE re i \ i h I a I (� REPLACE TANK OTHER 1 � S SOURCE OF DISCHARGE CAUSE(S) Q 5 ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE E] SPILL 4 O( PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER w w CHECK ONE ONLY v UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION ccy ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS O ❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 6 DISPOSE (ED) REMOVE FREE PRODUCT (FP) ElENHANCED BIODEGRADATION (IT) 0 0 (SEE BACK FOR WTMM ❑ CAP SITE (CD) ❑ EXCAVATE & TREAT (ET) PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) w a ❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) ❑ VACUUM EXTRACT (VE) ❑ OTHER (OT) 5��e wrre. k% q rpvvt p �w� (�vST SvT�..'�.�rge��o�ic� tvnsv\�C�n �bu"J g►�sn FP q 61 ri�CotZ� v� �\ 8 aCb W HSC 05 (a" 1 � S