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�► tea/ / L� <br /> 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 9 - <br /> ❑ YES No ❑ YES No I HERERYCERTIf FORMATION ACCORDING 70 THE <br /> REPORT DATE CASES DISTRI UCTgN SHEET ON THE BACK <br /> �PAGE <br /> OFy.TH FORM <br /> M MI cL ` Y <br /> NED B E <br /> NAME OF INDIVIDUAL FILING FOR PHONE SIGNATURE <br /> w REPRESENTING ❑ COMPANY OR AGENCY NAME <br /> F. OWNEFVOPERATOR ❑ REGIONAL BOARD <br /> s <br /> S -- ocAL AGENCY ❑ OTHER <br /> S <br /> � ADDRESS <br /> STREET CITY STATE <br /> J NAM/E] CONTACT PERSON ZIP <br /> PHONE <br /> ❑ UNKNOWN ���-/ <br /> /,-7 �O11/'/ <br /> wy ADDRESS lI /J�/✓� ///�r'�— y/ /� <br /> CITY ST— <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ATE Z, <br /> o Go . GOAP �t � S33-bogg <br /> tiADD/RESS \ ����QQ /^ / l/� J� <br /> w / L DI/ V�IJ i TREEr !r'�D! cm l'V� I <br /> y CROSS STREET cou P <br /> Gv f vfi <br /> i LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> ws.� co. <br /> w w REGIONAL BOARD <br /> O PHONE <br /> as <br /> NAME QUANTITY LOST(GALLONS) <br /> Z <br /> O UNKNOWN <br /> m (2) <br /> N <br /> ❑ UNKNOWN <br /> W DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> m w� D u� D o 1-/.[17 r r ❑ TANK TEST -TANK REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w u .1 r r UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE E::]REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK E FILL IN PLACE ❑CHANGE PROCEDURE <br /> F, ❑ VES ❑ NO IF YES,DATE E:]REPLACE TANK E:] OTHER <br /> M MI O Y <br /> SOURCE OF DISCHARGE CAUSES) <br /> j¢ ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> wO ❑ PIPINGLEAK "r CCC OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> yi CHECK ONE ONLY <br /> O ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTEDI <br /> CHECK ONE ONLY <br /> w� ❑ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> =y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> Q ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> IY£e.ral rw oE*Nal <br /> ai CAP CD <br /> w0 ❑ ( ) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY IRS) <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) O VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) � <br /> w Ln <br /> w <br /> f <br /> O <br /> Q <br /> HSG 051%9% <br />