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U DERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAKY CONTAMINATION SITE REPORT <br /> EMERGEjCY HAS STATE OFFICE OF E GENCY SERVICES FOR LOCAL AO USE ONLY <br /> REPORT BEEN FILED? I HEREBY CERTIFY THAT I AM A DESIGNOLGOMNMENT EMPLOYEE AND THAT I HAVE <br /> ❑Yes ❑No es ❑No REPORTED THIS INFORMATION TO LOC4111pr4CIALS PERSUANT TO SECTION 26180.7 OF <br /> THE HEALTH AND SAFETY CODE. <br /> REPORT DATE CASE# <br /> MIS DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> m <br /> w <br /> REPRESENTING COMPANY OR AGENCY NAME <br /> g I]LOCAL AGENCY 0 REGIONAL BOARD <br /> w OWNER/OPERATOR Ej OTHER... <br /> m ADDRESS <br /> STREET On STATE AP <br /> w <br /> PHONE <br /> NAME <br /> at NAME <br /> Unknown <br /> N ADDRESS <br /> W <br /> STREET QTY STATE aP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS <br /> w STREET OTr courRv ZIP <br /> F- <br /> � CROSS STREET <br /> LOCAL AGME AGENCY NAME PHONE <br /> w� <br /> g <br /> REGIONAL BOARD PHONE <br /> as <br /> f <br /> TI NAME QUANTITY LOST(GALLONS) <br /> V) <br /> W ❑Unknown <br /> m <br /> �z <br /> ❑Unknown <br /> $ DATE DISCOVERED HOW DISCOVERED ❑Tank Test ❑Tank Removal [3 Nuisance Conditions <br /> w <br /> ❑Inventory Control ❑Subsurface Monitoring [❑Other... <br /> a <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Y <br /> w ❑Unknown ❑Remove Contents ❑Close Tank <br /> 'o 13 Repair Tank 13 Change Procedure <br /> h HAS DISCHARGE BEEN STOPPED? ❑Replace Tank ❑Other... <br /> ❑Yes ❑No <br /> ❑Repair Piping <br /> IF YES,DATE <br /> U N SOURCE OF DISCHARGE CAUSE($) <br /> ❑Tank Leak ❑Piping Leak ❑Unknown ❑Other... ❑Overfill ❑Corrosion ❑Rupture/Failure ❑Unknown ❑Spill ❑Other... <br /> wW CHECK ONE ONLY <br /> ma <br /> L ❑Undetermined ❑Soil Only ❑Groundwater ❑Drinking Water -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ❑No Action Taken ❑Case Closed(Cleanup Completed or Unnecessary) <br /> W ❑Leak Being Confirmed ❑Pollution Characterization <br /> z ❑Remediation Plan ❑Post Cleanup Monitoring in Progress <br /> ❑Preliminary Site Assessment Workplan Submitted ❑Cleanup Underway <br /> ❑Preliminary Site Assessment Underway <br /> CHECK APPROPRIATE ACTION(S) <br /> 0 0 [3Cap Site(CD) [IExcavate&Treat(ET) [3Treatment at Hookup(HU) E3Other... <br /> W P (3 Contamination Barrier(CB) [3 No Action Required(NA) [3 Enhanced Bio Degradation(IT) <br /> 2W a ❑Vacuum Extract(VE) ❑Remove Free Product(FP) ❑Replace Supply(RS) <br /> ❑Excavate&Dispose(ED) ❑Pump&Treat Groundwater(GT) ❑Vent Soil(VS) <br /> 8 <br /> U <br />