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73 - <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE:ONLY <br /> REPORT BEEN FILED 4❑ <br /> ES NO YES NO <br /> 1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTED T1i1S INFORMATION ACCORDING TO THE YA ❑ ❑ <br /> I.DISTR SHOWN ON THE>)NS UCTIONSH ON THE BACKPAGE Df THIS FORM <br /> REPORT DATE CASE *.' <br /> M M Y SGNEII DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> >- ► .. <br /> w REPRESENTING F-1 OWNER/OPERATOR [:] GIONAL BOARD COMPANY OR AGENCY NAME <br /> gt54 LOCAL AGENCY ❑ OTHER Kd <br /> cc ADDRESS <br /> ® ET C STATE b 2p <br /> W NAME CONTACTPERSON PHONE <br /> J <br /> Z ❑ UNKNOWN C <br /> a a ADDRESS <br /> ws <br /> ' 1000 TREET I CITY STATE p <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> i <br /> k 3bo LAW. L <br /> a ADDRESS <br /> tl�P-RprLl l6uo /2 b U <br /> O <br /> W <br /> CITY COUNTY ZIP <br /> CROSS STREET <br /> O LOCAL AGENCf AGENCY NAME CONTACT PERSON PHONE <br /> zw <br /> fA <br /> w U <br /> 14 D <br /> w w REGIONAL BOARD PHONE <br /> 2< or, v CIS <br /> w® (9) NAME QUANTITY LOST(GALLONS) <br /> J ❑ UNKNOWN <br /> D z (2) <br /> D <br /> ❑ UNKNOWN <br /> I- DATE DISCOVERED HOW DISCOVERED ZiaINVENTORY CONTROL Q SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 2 M o o y y ❑ TANK TEST ❑ TANK REMOVAL OTHER j <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> ❑ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE F-]REPAIR PIPING <br /> W M D Y tl <br /> p HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK F--]CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> c ❑ YES ❑ NO IF YES,DATE M M D D v v ❑REPLACE TANK ❑ OTHER <br /> �j SOURCE OF DISCHARGE CAUSE(S) <br /> Q 5 ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL RUPTURE/FAILURE ❑ SPILL <br /> c O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN O OTHER <br /> www CHECK ONE ONLY <br /> U UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> I-0 <br /> ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED F-1 POLLUTION CHARACTERIZATION <br /> Q <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 BIO DEGRADATION(IT) <br /> J ISM BACK ran MALS) <br /> 4 Z <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) F-] VENT SOIL(VS) <br /> ❑rr VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> 6S <br /> g �'r 1 if LIZ <br /> ,/ ib e- <br /> he, <br /> O ® fs <br /> N <br /> If <br /> !p - 05(earn <br />