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a <br />a <br />HSG OS (�W <br />I( <br />19 <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY <br />HAS STATE OFFICE OF EMERGENCY SERVICES <br />FOR LOCAC`AGENCY USE ONLY:" <br />❑ <br />REPORT BEEN FILED? <br />YES ❑ No ❑ YES ❑ No <br />J HEREBY CERTIFYTHAT i HAVEDISTRIBUTEDTHIS INFORMATION ACCORDING TO THE. <br />..DISTRIBUTOR SHOWN CN THE.iNSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br />REPORTDATE <br />CASE+1 <br />M <br />MI © —/ v <br />SIGNED DATE <br />_. _ <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE <br />>- <br />m <br />(meq) 4468 - 3¢3 `? <br />kl �GU9z/ <br />w <br />REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD <br />OR AGENCY NAMEcc <br />R <br />Pg LOCAL AGENCY ❑ OTHER <br />�C.OMMPANY <br />�, �/)ry�� <br />J-� C� &J(�(R�(m�/jUlMr _ HF It^7� RW1V/ W 6x) <br />Lu <br />cr <br />ADDRESS <br />6 <br />��//� C /�•7�� A r' ( Q AG <br />t. lb" <br />STREET <br />t>�RON) `� CTI 'e, /(//V STATE tA&A 21P /s7 <br />w <br />NAME <br />CONTACT PERSON <br />PHONE <br />m <br />z <br />❑ UNKNOWN <br />( ) <br />O¢ <br />o_ a <br />(n <br />w <br />ADDRESS <br />cr <br />STREET CITY STATE ZIP <br />FACILITY NAME (IF APPLICABLE) <br />OPERATORPHONE <br />z <br />0 <br />r4 <br />ADDRESS <br />OU <br />Q,/ �� n � r <br />I _ _ _ _ STREET JA k- Cj' At CTl tz �/V COUNTY ZIP Y <br />y <br />CROSS STREET <br />O <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />z <br />W <br />6ilVWAJ Mft; Z- <br />w w <br />REGIONAL BOARD <br />PHONE <br />as <br />cn <br />(1) <br />NAME QUANTITY LOST (GALLONS) <br />W O <br />aJ <br />❑ UNKNOWN <br />z <br />(Z) <br />j <br />U) <br />��� <br />❑ UNKNOWN <br />Z <br />DATE DISCOVERED�7 <br />HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />w <br />O % <br />❑ TANK TEST ❑ TANK REMOVAL ® OTHER 5/�►�[,� ��j(%�[ �%1I�� <br />MI I D y ! y <br />co <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />a <br />2 <br />UNKNOWN <br />❑ REMOVE CONTENTS ❑ CLOSE TANK & REMOVE ❑ REPAIR PIPING <br />Lu <br />M M D Y Y <br />HAS DISCHARGE BEEN STOPPED ? <br />p <br />E]REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE <br />U <br />o <br />❑ YES ❑ NO IF YES, DATE <br />E] REPLACE TANK ❑ OTHER <br />M <br />MI D v Y <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />w <br />j < <br />❑ TANK LEAK UNKNOWN <br />❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br />env <br />❑ PIPING LEAK ❑ OTHER <br />❑ CORROSION 0 UNKNOWN ❑ OTHER <br />Lu w <br />CHECK ONE ONLY <br />U <br />❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />w <br />F—]NO ACTION TAKEN ❑ <br />PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />Q <br />j I <br />❑ LEAK BEING CONFIRMED ❑ <br />PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />U <br />❑ REMEDIATION PLAN ❑ <br />CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTION(S) <br />1SEE BACK Fan DETALS) <br />❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />a o <br />❑ CAP SITE (CO) <br />❑ EXCAVATE 8 TREAT (ET) ❑ PUMP d TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />ui <br />2 a <br />❑ CONTAINMENT BARRIER (CB) <br />❑ NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />❑ VACUUM EXTRACT(VE) <br />❑ OTHER(OT) <br />p <br />z <br />z <br />Lu <br />8 <br />HSG OS (�W <br />I( <br />19 <br />