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. • 6 - u'o ;�- UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICESFOR LOCALAGENCY USE:ONIY YES ❑ No REPORT BEEN FILED 7 YES ❑ NO 1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTEDTHIS INFORMATION ACCORDING TO THE. i01STRIBUTKN$SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM REPORT DATE / CASE i vM /M a SIGNED DATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNA�'RR �%m w REPRESENTINGOWNER/OPERATOfl ❑ REGIONAL BOARD COMPANY OR AGENCY NAME a ❑ LOCAL AGENCY OTHER ¢ ADDRESS 0'r �j ,/ / CJ STREET / CITV V, STATE ZIP U, NAME CONTACTPERSON PHONE J alU) y��/ /��a/� /— ❑ UNKNOWN � GT'� CL as ADDRESS �/�V '" /7 vy �/ /�� /C ,V �/I��G, �a.✓� C/ Q STREET CRY STATE ZIP FACILITY NAME(IF APPLICABLE) OPERATOR PHONE z ��r ��Nr /uc/J �' �� caa9� y UADDRESS Jr, O JCRY COUNTY W STREET ZIP N CROSS STREET O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE z m W -/f�s . E./ . r 1 w 61 REGIONAL BOARD PHONE a-a CVLvQG c W (1) NAME Q QUANTITY LOST(GALLONS) Z W �,V f-��a'-+QJ �c9�/moi-- Gera �n� _ v ❑ UNKNOWN Q J m O (Z) O ❑ UNKNOWN �— Z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS w aMi MI VDI DI bvI v ❑ TANK TEST ❑ TANK REMOVAL OTHER L a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) m a ❑Q UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE F--]REPAIR PIPINGoM M D D Y YU Q ' p HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE o YES ❑ NO IF YES,DATE MI D D v Y ❑REPLACE TANK �OTHER 211,rCOMIp� SOURCE OF DISCHARGE CAUSE(S) ja ❑ TANK LEAK ❑.UNKNOWN OVERFILL ❑ RUPTURE/FAILURE SPILL U ti ❑ PIPING LEAK OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER Lu wa CHECK ONE ONLY U UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY w F-1NOACTION TAKEN ❑ PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED E:] POLLUTION CHARACTERIZATION j ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS U ❑ REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ) ❑ ENHANCED BIO DEGRADATION(IT) J (SEE BACK FOR DETAL41 0 o❑ CAP SITE(CD) rt❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) w a ❑ CONTAINMENT BARRIER(CB) I I NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) ¢ ❑ VACUUM EXTRACT(VE) �Y❑�� OTHER(OT) c 4�)IV ��n-, �rc°6 0 /��fo A'Lr- A..,V4 cc-1t>e yr ok�fl 0 HSC 05(8/90)