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Ole <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES `FOR LOCALAGENCY USE ONLY":"-.-... <br /> E] YES NO REPORT BEEN FILED 7 YES ❑ NO 1 HEREBY CERTIFYTHAT I.HAVE DISTfiIBUTEIJTHISINFORMAMON.A000RDING TOTHE <br /> pISTRIBUTI.ON SHOWN ON.THE.INSTAUCTIOIV SHEET.ON 7 1{E BACK PAGE OF>THIS FORM <br /> REPORT DATE CASES <br /> M O qv DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> l r it Ug'-3,YO43,j r-4 <br /> LOU REPRESENTING ❑ ❑ COMPANY OR AGENCY N <br /> w OWNER/OPERATOR REGIONAL BOARD <br /> cc /� <br /> pLOCAL AGENCY ❑ OTHER S. � H�/ <br /> w <br /> I STATE <br /> Lu NAME } CONTACT PERSON PHONE <br /> z I f-�r f I �� El (cQ 61)�Ll <br /> w Qa ADDRESS <br /> f� 1 yq� 4 <br /> w �f3VQ� 8 cS-�D G��-t-(1 YL. C/�i <br /> 71!3,li 1 <br /> STREET CITY STATE Ip <br /> FACILITY NAME(IF APPLICABLE) C� OpV/ Ti PHON <br /> z <br /> O <br /> 1 a ADDRESS <br /> � 0 <br /> got <br /> Lu STREET CITY COUNTY ZIP <br /> � CROSS STREET <br /> z <br /> LOCAL AGENCYc AGENCYNAME CONTACT PERSON PHONE <br /> CZ) <br /> ^ <br /> w <br /> w Z <br /> w REGIONAL BOARD PHONE <br /> G ( ) <br /> NAME QUANTITY LOST(GALLONS) <br /> ` ^ U w <br /> �J < UNKNOWN <br /> (� o (2) <br /> ❑ UNKNOWN <br /> W DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING E::] NUISANCE CONDITIONS <br /> 6 MI M D� o� r r ❑ TANK TEST TANK REMOVAL OTHER —jy <br /> CD DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) �/C.7� <br /> w M o r yl UNKNOWN ❑REMOVE CONTENTS IJC I CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> p HAS,DI(SCHARGE BEEN STOPPED Z ❑REPAIR TANK /`��CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o I X I YES O NO IF YES,DATE I �M, a 3 o Y y ❑REPLACE TANK OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL E:] RUPTURE/FAILURE SPILL <br /> ❑ PIPING LEAK ✓ —] OTHER ❑ CORROSION UNKNOWN O OTHER <br /> w 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 /> w 0 NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> tr <br /> D N ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> o ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> J CHECK APPROPRIATEFMDETARS) (S) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> az <br /> w O ❑ CAP SITE(CD) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) F TREATMENT AT HOOKUP(HU) a VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> z <br /> coals <br /> o'Si <SOlw��e (L' <br /> HGr.as lA,cm <br />