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,l <br /> 4 ! �l ` <br /> UNDERGROUND ST <br /> ORAGEWANK UNAUTHORIZED RELEASE LEAK " ONTAM <br /> { (LEAK)) INATION SITE REPORT <br /> i EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LpCAL`AGENCY USE ONLY.:.::,REPORT BEEN FILED 7 <br /> 111 <br /> YES No ❑ YES NO E HEREBY CERTIFY THAT! HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> REPORT DATE D TI SHOWN THE WSTRUCTION SHEET ON THE BACK PAGE OF TH15 F <br /> ` CASE x <br /> QI I 1!� ' , <br /> J W SII d F� Y <br /> SIGNEDDA7 :>:: <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SI ATURE <br /> �J Ku6[� (moi ) Y� 'e .� <br /> m <br />( w REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME /J <br /> LOCAL AGENCY ❑ OTHER C //s �///� <br /> a Lu <br /> c ADDRESS ! L-d ftJ ` (7T \R <br /> I' �J <br /> STREETCm .r I v STATE l �� 21P J <br /> w r <br /> CONTACT PERSON ;` PHONE I <br /> o¢ ( G �( UNKNOWN iI p <br /> dto <br /> a ADDRESS <br /> l.. ✓ REFI" )"A 11 <br /> CRY LC STATE <br /> FACT ITY NAME(IF APPLICABLE) OPERATOR 14 <br /> PHONE <br /> a ADDRESS uI <br /> U <br /> cm 0OU'll <br />' O <br /> km CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON y. PHONE <br /> w� - y� <br /> w w REGIONAL BOARD RHONE <br /> CL a <br /> Lu (t} NAME QUANTITY LOST(GALLONS) <br /> EErQ <br /> Y UNKNOWN <br /> jZ <br /> coz <br /> i ❑ UNKNOWN <br /> r DATE DISCOVEREDI HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> ( u� OM� �cI o r r ❑ TANK TEST � TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> srt D Y UNKNOWN E:]REMOVE CONTENTS CLOSE TANKS REMOVE L]REPAIR PIPING <br /> I p HAS DISCHARGE BEEN STOPPED T ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> 4 0 2YES ❑ NO IF YES,DATE 1 0u Y S Y ❑REPLACE TANK I ❑OTHER <br /> SOURCE OF DISCHARGE CAUSES) I <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE E] SPILL <br /> v ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> IF. i <br /> Lu a CHECK ONE ONLY ` <br /> I v ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER.-(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHg ONE ONLY i <br /> w 5 NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTEDLILJ POLLUTION CHARACTERIZATION <br /> a:I- <br /> y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY I E:] POST CLEANUP MONITORING W PROGRESS <br /> U ❑ 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 /> (sEE 9FGK fOR CEl AlSI - �� <br /> E p ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> tau a <br /> ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) E] TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) <br /> 0 <br /> U - <br /> HSC US(890/ <br />