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• ! u..8 t <br /> UNDERGROUND STORAGE TANK UNAUTHO ZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVII15ESFORLOCALAGENCY'.USEONLY <br /> REPORT BEEN FILED 7 <br /> ❑ YES 00<0 [:) YES NO 1HE CERRFYTHATI HAVE DISTRIBUTED THIS INFORMATION.ACCORDING TO THE <br /> DI RIBU ON SHOWN ON THE I 'F1RUCTTSHE N THE BACK PAGEOFTHIS FORM <br /> REPORT ATE vn' CASE• <br /> N OF INDIVIDUAL I NIS ��R � PHONE I SIGNATURE <br /> m <br /> ❑ REPRES ING ❑ ❑ COMPANY OR AG NCV NAME <br /> w OWNER�OPERATOR REGIONAL BOARD <br /> g LOCAL AGENCY ❑ OTHER <br /> ¢ ADD ESS (/J�///�V�//�/✓j/ Sr//////,^ /JJ�� /-/^�//7J //j.L,�/�/�/�jj`//���^^/l <br /> 5 � �-"STREET � � ✓ ,CITI� �' � " ' STATE Z <br /> CONTACT PERSON PHONE <br /> i¢ Dr " ❑ UNKNOWN ` ( ) qy� <br /> a n ADDRESS 1+/ILe ��///n-y/V�/{J /Q 9fr�+/�//�/ <br /> ¢ I_ V_KSTREET �� l� Com/ STNTE / ✓(/rIP <br /> ZIP <br /> ,PAJILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS <br /> 0-f � /�/��/J j/�I .ori 9y/6-0z 6 <br /> REEF�� I{y ' <br /> P <br /> Ds I C S STREET <br /> Wood zl <br /> 0 LOC AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> wU <br /> w M REGIONAL BOAR 41 PHONE <br /> vv y <br /> w (1) - NAME QUANTITY LOST(GALLO <br /> a 0 02UNKNOWN <br /> (z) <br /> N <br /> ❑ UNKNOWN <br /> i DATEDI VERED Y HOWDISCOVERED ❑ VENTORV CONTROL ❑ SUBSURFACEMONITORING ❑ NUISANCE CONDITIONS <br /> w ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> s <br /> lil M M 0 V <br /> FQ DATE DISCHARGE BEGAN , METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> ¢ u o o r Y LJ "NKNOWN ❑REMOVE CONTENTS ,L_J�CLOSE TANK 8 REMOVE ❑REPAIR PIPING <br /> w <br /> p HAS DIS ARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK 8 FILL IN PLACE E::]CHANGE PROCEDURE <br /> O <br /> o YES E:] NO IFYES,DATE M o Y r ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> y0 ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> ywn CHECK ONE ONLY <br /> OZ ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w� ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> M;5 ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE d DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> 13£MCK ial OEf�� <br /> a <br /> wo ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMPB TREAT GROUNDWATER(GI)❑ REPLACE SUPPLY IRS) <br /> r <br /> w< ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) !ln <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> HSC 05149% <br />