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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 /> VES �NO ❑ YES �UaIj N <br /> REPORT BEEN FILED? /O I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ <br /> DISI BUTTON SH ON THE IMSTRVCTION SHEET ON THE BACK PAGE OF HIS F M. <br /> REPORTDATE <br /> �') q t CASEd <br /> l.av 'SIGNED' / DA E <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIG ATURE <br /> kLoi kk)OL�-- vlo7 )ytF- ii <br /> R RESENTING COMPANY OR AGENCY NAME <br /> ❑ OWNER/OPERATOR REGIONAL BOARD <br /> p LOCAL AGENCY ❑ OTHER <br /> a <br /> a ADDRESS <br /> PXp' -FI O-C /�J" ST(J(J�( <br /> REET S c CA 4h t,o388 <br /> J NAME CONT TPERSON PHONE p <br /> W N ❑ UNKNOWN <br /> oa <br /> a u ADDRESS /L'{/ 9 <br /> ¢ -O Zo Y�. ` TREE! C/ � iTAI <br /> FACILITY tlAME(IF APPLICABLE) OPEPHONE <br /> RATOR <br /> E K. v res ) �1 -.-1:72v <br /> Q ADDRESS <br /> m CR77OOS/SS ST ET <br /> Y> <br /> o LOCALAGENCY AGENC NAME rONTApTPERSON PHONE <br /> w� <br /> 3 ` <br /> w w REGIONAL BOARD PHONE <br /> y ( NAME QUANTITY LOST( LLONS) <br /> wo <br /> QJ C UNKNOWN <br /> m i (2) <br /> �- <br /> `� ❑ UNKNOWN <br /> i <br /> DATE <br /> 11 DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> M cul L' o� T of v V r ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> am DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> u M v v <br /> UNKNOWN E]REMOVE CONTENTS ❑CLOSE TANK 8 REMOVE ❑REPAIR PIPING <br /> o <br /> H S DISCHARGE BEEN STOPPED 7 M REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o YES ❑ NO IF YES.DATE M MI o v r ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSEIS) <br /> j ❑ TANK LEAK X UNKNOWN ❑ OVERFILL RUPTURE/FAILURE ❑ SPILL <br /> 0 <br /> 0 ❑ PIPING LEAK ❑" OTHER ❑ CORgOSION UNKNOWN ❑ OTHER <br /> ww CHECK ONE ONLY <br /> N R <br /> O ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER E::] DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> iZ ❑ NOACTIONTAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w <br /> �r ❑ LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ON ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> ISFFBKF�rn oFiNbl <br /> « CAP SITE EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER G <br /> 0 0 ❑ ❑ ❑ ( T)❑ REPLACE SUPPLY(RS) <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP({�U) ❑ VENT SOIL(VS) <br /> !� <br /> �❑ VACUUM EXTRACT(VE) OTHER( (//yj/ , /rr��,�(�. (( J p <br /> TU �/JR/I "' " `• ,{,'Cln �1J¢ C WG( <br /> w U - Q <br /> s �/Wo� , ��t�yt_�-., ,fid-(i� �& tom <br /> N9C 0,b9% <br />