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UNDERGR UND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY NHAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> Q VES O YES NO <br /> REPORT BEEN FILED 7 1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> Q Q <br /> DISTRIBUTION SHOWN IXJ THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE / q �J CASE6 <br /> 0 _ R.�'7 -I f <br /> `J! / J Y SIGNED d .. DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> z..— 0171 Y6�3Y <br /> REPRESE Q OWNEPoOPERAT3R Q REGIONAL BOARD COMPANY OR AGENCY NAME <br /> ¢ LOCALAGENCY Q OTHER <br /> S <br /> a ADDRESS <br /> SS� <br /> ur �pjU,N I <br /> STREET CITY STATE ZIP <br /> j NAME CONTACTPERSON PHONE <br /> /�� / <br /> z� C LO(�✓Un 5" ❑ UNKNOWN `'ej A ( S� L' 10 <br /> vOai u ADDRESS <br /> f 70p-a" cmSCJ <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> So (av p63 <br /> ADDRESS ���� C ' '' /u✓!/[ (/l/ � �rr`� S, <br /> 3t Try COUNTY ZIP <br /> ILI <br /> y CROSS STREET p LOCALAGENCY AGENCY AME CONTACT PERSON PHONE <br /> 2 y <br /> z <br /> 2 W <br /> w. REGIONAL BOARD PHONE <br /> y (�) NAME QUANTITY LOST(GALLONS) <br /> i ❑ UNKNOWN <br /> a� <br /> m i (2) <br /> UNKNOWN <br /> i DATE DISCOVERED •_l HOW DISCOVERED ENTORY CONTROL Q SUBSURFACE MONITORING Q NUISANCE CONDITIONS <br /> M o Y 3r ❑ TANK TEST TANK REMOVAL ❑ OTHER ` <br /> mDATE DISCHARGE BEGAN METHOD USED TO STOP DISCHAR HECK ALL THAT APPLY) <br /> UNKNOWN Q REMOVE CONTENTS CLOSE TANK REMOVE REPAIR PIPING <br /> W M D Y Y <br /> HAS DIS YES GE❑BEEIN STOPPED 77 L_j REPAIR TANK M o r Y ❑REPLACE TANK Q OTNERTANK&FILL IN PLACE Q CHANGE PROCEDURE <br /> 0NO IF <br /> SOURCE OF DISCHARGE CAUSES) <br /> c j ❑ TANKLEAK Q UNKNOWN Q OVERFILL Q RUPTURE/FAILURE Q SPILL <br /> H� F-1 PIPING LEAK Q OTHER IJ CORROSION Q UNKNOWN Q OTHER <br /> w w CHECK ONE ONLY <br /> Q UNDETERMINED Q SOIL ONLY Q GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> C14ECKONEONLY <br /> i� ❑ NO ACTION TAKEN Q PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED Q POLLUTION CHARACTERIZATION <br /> �y Q LEAK BEING CONFIRMED Q PRELIMINARY SITE ASSESSMENT UNDERWAY Q POST CLEANUP MONITORING IN PROGRESS <br /> O Q REMEDIATION PLAN Q CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) Q CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) Q REMOVE FREE PRODUCT(FP) Q ENHANCED BIODEGRADATION(IT) <br /> J Z I✓�6YII N]I DEIN81 <br /> o O ❑ CAP SITE(CD) Q EXCAVATE&TREAT(ET) Q PUMP&TREAT GROUNDWATER(GT)Q REPLACE SUPPLY(RS) <br /> wF <br /> w< ❑ CONTAINMENT BARRIER(CB) Q NO ACTION REQUIRED(NA) Q TREATMENT AT HOOKUP(HU) Q VENT SOIL(VS) <br /> Q VACUUM EXTRACT(VE) Q OTHER(OT) <br /> z Fiv1 . 5i/f arStsr � y c i// -4t hQcwc tri q��wtAy iLo K(� �c�A� <br /> y /o c --p ewo <br /> u dr c V <br /> NSC�lasol <br />