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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 <br /> ❑ YEs NO ❑ YESO 1 HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> REPORT DATE CASE>r <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. <br /> �) <br /> M v r SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> � <br /> Gi ,�/"� (zoo ) `l6 s -3+i 2I •C/ - r <br /> wo REPRESENTING OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> O ❑ LOCAL AGENCY ❑ OTHER <br /> C- <br /> ¢ ADDRESS 'n <br /> /(;© '�9fRE ,j q�7�Q� STATE <br /> Lu NAME CONTACT PERSON PHONE <br /> J <br /> m <br /> Z o ❑ UNKNOWN ) <br /> CL a ADDRESS <br /> w <br /> ¢ <br /> STREET CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> U ADDRESS <br /> O � <br /> J <br /> LJ ��s .. 2 ��Y S� �-To. ,1 ZAP <br /> ai CROSS STREET <br /> O LOCAL AGENCY, AGENCY NAME CONTACT PERSON PHONE <br /> zN <br /> z w 1 ) <br /> w U <br /> w Luz0REGIONAL BOARD PHONE <br /> w (1) NAME QUANTITY LOST(GALLONS) <br /> U O <br /> w �iti.q/l <br /> c J �.�rG NKNOWN <br /> m (Z) <br /> �z <br /> y <br /> UNKNOWN O <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING j❑ NUISANCE CONDITIONS O <br /> w MI MI DI DI YJ r ❑ TANK TEST ❑ TANK REMOVAL ®"'OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> a <br /> } UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK 8 REMOVE ❑REPAIR PIPING <br /> ¢ .1 M D D Y Y <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK E FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> YES ❑ NO IF YES,DATEM <br /> MI D V Y ❑REPLACE TANK OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> D a ❑ TANK LEAK F-] UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> co O ❑ PIPING LEAK E216THER a CORROSION ❑ UNKNOWNOTHER <br /> w w CHECK ONE ONLY <br /> U ❑ UNDETERMINED OIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w NO ACTION TAKEN F-1PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> crI � LEAK BEING CONFIRMED ❑PRELIMINARY SITE ASSESSMENT UNDERWAY � POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> Z <br /> o O ❑ CAPS ITE(CD) AVATE 8 TREAT(ET) ❑ PUMP 8 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> LU <br /> w a F-1CONTAINMENTBARRIER(CB) NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> ¢ ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> m <br /> z <br /> z <br /> w <br /> 0 <br /> O <br /> U <br /> HSC 05(8190) <br />