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A lb 0 1-[ <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/C NTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES NO REPORT BEEN FILED 7 ❑ YES ❑ NO I HEREBY CERFIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTI SH N ON THE INSTRUCTION SHFET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE 4 CASES <br /> DN 9'M ( 7 Y DATE. J <br /> NAME OF INDIVIDUAL FILING REP TPHONE SIGNATURE <br /> w REPRESENTING ❑ OWNERLOPEFUTO REGIONAL BOARD COMPA ORAGENCYNAME <br /> ¢ LOCALAGENCY ❑ OTHER <br /> S <br /> ¢ <br /> ADDRESS <br /> '✓ STREET CITY STATE ZIP <br /> J NAME (\� Cu, CONTACT PERSON PHO/,NE (j <br /> Z, c. V V� L/fUNKNOWN /\J1 .f �, bib/b? / �/^ <br /> ma ADDR 'ESS <br /> D O REeT �1...�[/•�crrr V�V V yVY v s*ATE /� A J <br /> w y <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> a� j ,L t <br /> a ADDRESS <br /> N CROSS STREET <br /> l <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w w REGK)N,r�I��BO�A/RD� /^ PHONE <br /> E <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> i wTs <br /> UNKNOWN <br /> a <br /> m i R) <br /> y I O ..n /J ❑ UNKNOWN <br /> i DDAA)TE DISCOVERED �-- HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ,N,UI�SANCCE¢CONDITIONS <br /> w " M 7.1 �o �r �x ❑ TANKTEST TANK REMOVAL OTHER w, /}_y?yt( <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP UNKNOWN ❑REMOVE CONTENTS DISCHARGE <br /> SJ4CGOSE TANKS REMOVE APPLY) <br /> PIPING <br /> j mi d Di <br /> w HAS DISCHARGE❑E NOSTO YESYDATE T© L7 'Ml o 1 dq Y 7 Y O REPAIR TANK �O`CLOSE TANK 6 FILL IN PLACE ❑CHANGE PROCEDURE <br /> YES REPLACE TANK OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> v TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> �n ❑ PIPING LEAK ❑ OTHER CORROSION ❑ UNKNOWN ❑ OTHER <br /> mn CHECKONEONLY <br /> V ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHEECCKKONEONLY <br /> w IyI NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> �y �❑ 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 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> � (sFE eu Ra.onu8l <br /> a ❑ CAP SITE(CO) EXCAVATE 6 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)E:] REPLACE SUPPLY(RS) <br /> OD <br /> wr <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ¢ <br /> VACUUM EXTRACT(VE) OTHER(OT) <br /> ❑ <br /> 8 dz'llfv� v <br /> Im MR&M <br />