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P <br /> UNDERGROUND STORAGE T NK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES AORLQCAC AGENCY USE:ONLY <br /> ❑ YES NO REPORT BEEN FILED ®YEs NO 1HEREBYCERTIFYTHATi.HAVEDIST U7EDTHISINFORMATION QiNGTOTHE <br /> TSV QWNON ION HEUDN THE, P 'OFTHLSFORNI ..., <br /> R R A CASE& s <br /> M �Iv S DATE is <br /> Nip OF INDIVIDUAL FILING REPORT PHONE SIGNA <br /> > 926W61, J. / ( (�) S <br /> m <br /> w REPRESENTING ❑ OWNER/OPERATOR 0 REGIONAL BOARD COMPANY OR AGENCY NAME <br /> cc <br /> LOCALAGENCY ❑ OTHER <br /> cc A16DRESS G <br /> STREET J cm STATE zi <br /> w NAM NTACTPERSON PHONE <br /> zUNKNOWN <br /> cn Q. <br /> ADDRESS <br /> w <br /> -10 <br /> cc <br /> CRUJ STFI f, C STATE (p <br /> FACILITY N E(IF APPLICABLE) OPERATOR PHONE <br /> O ( ) <br /> ADDREIA ID o 7.Z., <br /> WBEET/ / CRY COUNTY ZIP <br /> y <br /> CROS9 STREET <br /> O <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> zFfem <br /> )_ ` A I 9 <br /> zW �V T <br /> wof <br /> w wRE NAL BOA p E <br /> as <br /> m (1) NAME QUANTITY LOST(GALLONS) <br /> w <br /> z Lu UNKNOWN <br /> ®z (2) <br /> D� <br /> UNKNOWN <br /> rz DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING Q NUISANCE CONDITIONS <br /> MI MI d oI r Y ❑ TANK TEST ® TANK REMOVAL OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M o r r <br /> UNKNOWN REMOVE CONTENTS [::]CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> M <br /> p HAS DISCHARGE BEEN STOPPED 4 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> D ❑ YES NO IF YES,DATE M MI o o v Y ❑REPLACE TANK E:]OTHER <br /> SOURCE OF D16CARGE CAUSE(S) <br /> TANK LEAK UNKNOWN ❑ OVERFILL ® RUPTURE/FAILURE SPILL <br /> N o ❑ PIPING LEAK F-� OTHER F--j CORROSION UNKNOWN O OTHER <br /> Lu w CHECK ONE ONLY <br /> U ❑ UNDETERMINED ❑ SOIL ONLY YGROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED E] POLLUTION CHARACTERIZATION <br /> n <br /> w BEINGF--j LEAK <br /> ❑ RE EDIAT OCONFIRMED <br /> MED PRELIMINARY <br /> ❑ CASE CLOSED(CLEANUP COMPLETED OR NNECESSARY) ❑ CLMONITORING IN PROGRESS <br /> EANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ED REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J (SEE BACK FOR DETAILS) <br /> a <br /> CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> uj <br /> E3 O <br /> ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTON REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) F-� OTHER(OT) <br /> Z <br /> w <br /> /!Q jT ® C <br /> 3 <br /> HSC 05I <br />