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UNDERGROUND STORAGE TANK (UST) SITE - UNAUTHORIZED RELEASE 1 CONTAMINATION REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑Yes NO REPORT BEEN FILED? Yes ❑ No I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTI N /I 2518Q9.7 OF <br /> REPOR IDAA�yT CASE# THE HEALTH AND SAFETY B'E:� 1 11 ) 9Jq <br /> v I SIGNED DATE/ <br /> rADYRESS <br /> IDUAL FI G REPORT PHONE SIGNATURE <br /> m C MPANY OR AGENCY NAME <br /> 0 <br /> wCY ❑ REGIONAL BOARD Jl� <br /> 0RATOR ❑ OTHER /���'(� <br /> E` , C L4' ISM� <br /> all <br /> CITY S�T/AT/E ZIP <br /> NAMEMatt TP RSO PHONE <br /> m El Unknown � <br /> / ) <br /> w' <br /> 0 a <br /> w ADDRESS <br /> /X <br /> � /� � �t' <br /> ��,!/ <br /> STREET STATE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> 0 ( ) <br /> P: ADDRR'yE�SS �j� <br /> LU C24 <br /> 3/ 5STREET / _" • au Y - � COUNTY ZIP � <br /> CRW STREET <br /> LOCAL AGENCY AGENCY NAME PHONE <br /> Z ^ <br /> z <br /> UJ <br /> ZU i <br /> w Z <br /> w R ONAL BOARD PHONE <br /> IL <br /> a AM 4(61/ � <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> Z>� a / ❑ Unknown <br /> wo <br /> Q J <br /> CQ o (2) <br /> n nown <br /> DATE DISC VERED HOW DISCOVERED <br /> z / �7 Tank Test Tank Removal ❑Nuisance Conditions <br /> w JP l ❑Inventory Control ❑Subsurface Monitoring Other <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> } Remove Contents Close Tank <br /> w Unknown ❑Repair Tank ❑ Change Procedure <br /> o HAS DISCjiARGE BEEN STOPPED? ❑ Replace Tank Other <br /> o ❑Yes No IF YES,DATE ❑ Repair Piping <br /> w SOURCE OF DISCHARGECAUSES) <br /> 00 <br /> a Tank Piping E3Dispenser [--] Delivery Problem ❑Spill [:1 Overfill ElPhysical/Mec nical Dam e ❑Corrosion <br /> o ❑Subm rsible Turbine Pump(STP) ❑Other ❑Installation Problem ❑ Unknown Other <br /> WW CHECK ONE ONLY <br /> cn a <br /> a Undetermined ❑ Soil Only ❑Groundwater ❑ Drinking Water—(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ❑OSite At El <br /> w pen- Assessment <br /> Open-Verification Monitoring <br /> X< _[I Open-Assessment&Interim Remedial Action El Open-Inactive <br /> U Open-Remediation ElClosed—No Further Action Required <br /> z CHECK APPROPRIATE ACTION(S) <br /> 0 Human health exposure control? ❑Yes [I No Unknown <br /> Groundwater migration control? ❑Yes ❑No gunknown <br /> a ❑No Action Required(NAR) El Excavate&Treat(ET) El Treatment at Hookup(TH) El Other <br /> 0 <br /> w El Excavate&Dispose(ED) ❑ Free Product Removal(FPR) ❑Replace Supply(RS) <br /> w <br /> an, - C,1. -X Ne*"ewl 041 Iaoi- It L'OYtStn4^" �nf <br /> w <br /> 0 <br /> 0 <br /> U <br /> SWRCB Leak Report Form http://www.s-Areb.ca.gov/water issues/programs/ust/forms/ Rev.02/01/2012 <br />