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9tH <br />t <br />CDHSC 05 (8 <br />7 <br />0 <br />tcl- <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EM[RGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />FOR LOCAL AGENCY USE ONLY " <br />F--1 YES F-1 No REPORT BEEN FILED 7 ❑ YES ❑ NO <br />I HEREBY CERTIFY THAT i. HAVE DISTRIBUTED THIS INFORMATION ACCORDING T&4 <br />DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET QN THE BACK PAGE 'OF' 1 HIS FORM <br />REPORT DATE <br />O <br />CASE <br />M <br />SIGNED A <br />NAME OF FILING REPORT <br />PHONE <br />SIGNATURE �r <br />co <br />PNIVIDUAL <br />` <br />/� 2 <br />1 <br />o <br />REPRESENTING OWNER/OPERATOR ❑ REGIONAL BOARD <br />C MP OR AGENCY AME <br />p❑ <br />LOCAL AGENCY THHEERR <br />C <br />Crw <br />ADDRESS <br />/� <br />(;q CW— - C Q <br />STREET I CITU STATE ZIP <br />J <br />NAME ��� ® `' ^^ O <br />CONT ERSO <br />PHONEco <br />z <br />t� UNKNOWN <br />` j^ <br />/ - / t/ <br />�(� <br />�� ( o <br />ui <br />ADDRESS <br />cc <br />STREET CITY STATE ZIP <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />PHONE <br />o <br />( 46 — <br />ADDRESS 14� <br />w <br />v STREET CITY COUNTY Zlp <br />CROSS STREET fJ <br />O <br />LOCAL AGENCY GENCY NAME <br />CONTACT PERSON �a [/ <br />,c7 <br />PHONE <br />�, <br />o�� <br />` <br />W U <br />`/ <br />w <br />REGIONAL BO <br />PHONE <br />as <br />� <br />I <br />` I <br />m <br />(1) NAME QUANTITY LOST (GALLONS) <br />aLLo <br />q �`, � ❑ UNKNOWN <br />co zco <br />(Z) <br />U) <br />❑ UNKNOWN <br />Z <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ INVENTORY CONTROL 0 SURFACE MON/�y�ORING 0 CONDITIONS <br />LLJ <br />w <br />/ al Cr, 3r <br />/%NUISANCE <br />❑ TANK TEST E] TANK REMOVAL OTHER <br />MI '21.1 o <br />a <br />m <br />DATE DISCHARGE BEdAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />` ❑ UNKNOWN <br />[-]REMOVE CONTENTS 0 CLOSE TANK & REMOVE ❑ REPAIR PIPING <br />w <br />00 <br />M <br />HAS DISCH GE BEEN TOPPED 4 <br />❑ REPAIR TANK 0 CLOSWANK L IN PLACE CHANGE PROCEDURE <br />U) <br />_ <br />YES ❑ NO IF YES, DATE I I <br />❑REPLACE TANK HER <br />u D v <br />D r <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />Ca <br />om <br />❑ TANK LEAK ❑ UNKNOWN <br />❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br />L) <br />❑ PIPING LEAK OTHER <br />❑ CORROSION ❑ UNKNOWN OTHER <br />w w <br />U) a <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 />wF--]NO <br />ACTION TAKEN 0 PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED 0 POLLUTION CHARACTERIZATION <br />cr N <br />❑ LEAK BEING CONFIRMED ❑ PR (NARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />U <br />❑CASE CLOSE ❑ CLEANUP UNDERWAY <br />REMEDIATION PLAN <br />J <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <br />ISEE BACK FOR DOA") <br />o <br />o O <br />❑ CAP SITE (CO) F -] EXCAVATE& TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />a <br />❑ VENT SOIL( ) <br />❑ CONTAINMENT BARRIER (CB) ❑ NO ON REQUIRE (N) ❑ T TMENT AT HOOKUP (HU)Cc <br />❑ VACUUM EXTRACT (VE) OTHER (OT) (� i ^ %u (� <br />Co ti, Y' G D (ti � r <br />z(� <br />Lu <br />r <br />1-m �� Pic? A, L e- <br />p <br />{� �/!. L f ! <br />0 U <br />9tH <br />t <br />CDHSC 05 (8 <br />7 <br />0 <br />tcl- <br />