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a — c� � . <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> —d <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED Z O 1 HEREBY CERTIFYTHAT 1 HAVE DISTRIBUTED THIS INFORMATION ACCORDING TOTHE; <br /> ❑ YES ❑ NO <br /> E:] YES DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE CASE i � <br /> U M MI U N SIGNED DATE <br /> N ME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> REPRESENTING WNER/OPERATOR ❑ REGIONAL BOARD COMPANY OOR/AAGGENCY NAME <br /> pF-] LOCALAGENCY ❑ OTHER t' >'`� ���� r G <br /> cc: ADDR S ) Ci P • , D <br /> I STREET CITY STATE ZIP <br /> NAME CONTACT PERSON I r PHONE ��,a� <br /> m PI/�D�C/W' -� ❑ UNKNOWN l tS VY `LOQ l .-10) L�`r �J <br /> U) <br /> z / r <br /> a s ADDRESS a r k-f-i V S C D <br /> CITYSTATE <br /> tr TREET P <br /> S <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> L s c�der ) <br /> s(,kja.0ca j Q r kj <br /> ~ ADDRESS <br /> Q //�� /yw' (��(/��(, L©�(' 4 <br /> `' ` • COUNTY ZIP / J <br /> w <br /> 8 <br /> 00 ET CITY <br /> ~ CROSSSTREET'. ' <br /> y � <br /> K j AGENCY NAME CONT CT PERSON PHONE <br /> O LOCAL AGENCY <br /> z (20 468— 4� <br /> e li - a6 <br /> Lu O �/ �• L� eQ �( PHONE <br /> w w REGIONAL RD <br /> a a ( ) <br /> NAME , L//QUANTITY/LOST(GALLONS) <br /> W W (�) (fing S I .' . L El UNKNOWN <br /> 0 Lu0 <br /> z 0 <br /> z (2) ❑ UNKNOWN <br /> fn <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE <br /> M NITORING NUISANCE CONDITIONS <br /> w W <br /> YI ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BE(IAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> ❑ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> w M M D D Y <br /> 0 HAS DISCH BEEN STOPPED Z ❑REPAIR TANK ❑CLOSE TANK& ILL IN PLACE CHANGE PROCEDURE <br /> O /r CLQ <br /> cn o YES ❑ NO IF YES,DATE 0.1 M o D y ❑REPLACE TANK THER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> La 2 ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> r <br /> O ❑ PIPING LEAK d" <br /> F-1OTHER ❑ CORROSION ❑ UNKNOWN OTHER <br /> w w CHECK ONE ONLY e ©� <br /> U)a <br /> U ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w ❑ <br /> � ❑ LEAK BEING CONFIRMED ❑ P IMINARY 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,ECy ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) C <br /> (SEE HACK FAR DETAISj <br /> <z EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ❑ CAP SITE(CD) ❑ <br /> III NO A ION REOUI ED(NA) TREATM NT AT HOOKUP(HU) ❑ V NT SOIL(VS) <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ /^1q �� n rn <br /> WCMX ( OTHER(OT) Cilcf, x�l <br /> V O t pck t'�— J(:g e-w <br /> z 2 7 1992 ✓nal�c � �a 5-le- <br /> APR <br /> w <br /> �I NMENTAL HEALTH �tQ � V�� � �u S t - <br /> E O ��' <br /> HSC 05(690) <br />