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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> YES <br /> REPORT BEEN FILED 7 ❑ YES NO <br /> j HEREBY:CERTIfYTNAT l HAVE DIS7RIBUTEDTHIS INFOR tr4ATIONACCORDING TO THE:- <br /> ❑ NO ❑ <br /> OI 18 TION SHOW_ON THE INSTR CTIO SHEET ON THE BUCK?AGE OF TH IS FOR M <br /> REPORT DATE CASE 11. <br /> 2 �fJ51, <br /> M M J VS N DAT <br /> N OF INDIVIDUAL FILIbIG AEPORT PHONE SI TU <br /> tY37c— 9 <br /> w REPRESENTING WNEFVOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> cc <br /> ❑ LOCAL AGENCYE] OTHERcc �^ <br /> Q Q� <br /> ADDRESS Q ^ v1.O�GC ,�(n/e/.L/ J t-� � � �a•'� �•,L� j L/� l <br /> �L/` STREET CITY STATE ZAP <br /> w NAME �n CONTACT PERSON PHONE <br /> co <br /> �( 7 <br /> U SOV��.la �� L�j�e7OL� ❑ UNKNOWN r O ✓ - l LlL'1U �J "J' 7-7/1 <br /> a ADDRESS <br /> CZIPITY COL a ©r.c TS <br /> Ir <br /> m A <br /> FACILITY NAME(IF APPLIC L OPERATOR / o PHONE <br /> c 17VI (.0 L,C 6cr c <br /> ADDRESS F__S� l'��flel�` v�Lt�/� 'r`-(d ALT -�C� CL�l J <br /> STREET / Cm' COUNTY ZIP <br /> W <br /> �= CROSS REST <br /> LOCAL AGENCY AGENCY N4ME CONTACT PERSON PHONE <br /> Z6 z&tt-,T � �l �� l l / <br /> v �Lc ,c �Ca pv uS a r r r� �h o l( (Z�` 3yy <br /> w w REGYONALBOA PHONE <br /> J 0 1/ 1 <br /> (L Q ♦ I <br /> U) NAME QUANTITY LOST(GALLONS) <br /> Z> So <br /> ��1lfiKNOWN <br /> Q J <br /> m Z (2I <br /> W <br /> ❑ UNKNOWN <br /> z q� <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> ui <br /> MI M O p <Y Y ❑ TANK TESTANK REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Eg <br /> UNKNOWN ❑REMOVE CONTENTS LOSE TANK&REMOVE ❑REPAIR PIPING <br /> LLJM D Y Y <br /> O HAS DISCHARGE BEEN STOPPED 7 2 D [ Q ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o YES ❑ NO IF YES.DATE [ V ❑REPLACE TANK ❑OTHER P <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> a ❑ TANK LEAK NKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> y v ❑ PIPING LEAK ❑ OTHER E] CORROSION NKNOWN ❑ OTHER <br /> N wa CH=UNDETERMINED <br /> Y <br /> O ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER •(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w ❑ NO ACTION TAKEN RELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ❑ 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 /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) 0 ENHANCED BIO DEGRADATION(IT) <br /> aZ ISEE BACK row DUAM <br /> F3 O ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ <br /> OTHER(OT) <br /> z10 <br /> HSC 05(SNDI <br />