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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 /> ❑ YES NO REPORT BEEN FILED 7 ❑ YES ❑ NO i HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> REPORT DATEDI IBU TION SHOWN ON13H5 INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> CASE s CA r t t <br /> L M IMI l� d �d Cwt S r SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIG TURE <br /> w REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> OLOCAL AGENCY ❑ OTHER al/ qqc Lt �b, Ck k 1-(-?, pe-a,4A <br /> w <br /> cr <br /> ADDRESS <br /> -�o " C STREET' R r <br /> CIT' STATE ZIP <br /> Lu NAME p- \ 2�} (� CONTACTPERSO�f{{ /� PHONE /+ <br /> Z 2 1�v N / 1� � �T�' ❑ UNKNOWN 1 v� C �� (civ <br /> a 0- ADDRESS <br /> cc STREET CfTY STATE 71P <br /> FACILITY NAME(IF APPLICABLE) �/-��/�O OPERATOR <br /> , PHONE <br /> p I Y 1 l� V is V YV� ( ) <br /> Q ADDRESS <br /> CITE COUNTY ZIP <br /> CROSS STREET <br /> L0Co��� <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z STL, env, �- „)), �j X% <br /> w <br /> w U <br /> w w REGIONALBOARD PHONE <br /> (�) ///�J�(� o NAME QUANTITY LOST(GALLONS) <br /> LU ao 1�,/�--�U '� �e. UNKNOWN <br /> m> (2) <br /> U <br /> ❑ UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lij -:3r ❑ TANK TEST ❑ TANK REMOVAL FV OTHER Sad b(�ln <br /> < DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> a <br /> = u o r r <br /> UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE F7 REPAIR PIPING <br /> M <br /> w <br /> pHAS DISCHARGE BEEN STOPPED? n�'^��,� ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o YES F] NO IF YES.DATE ml� MI l DI of Yj Y ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> ¢j ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> D Q <br /> v F7PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> Na <br /> U ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> c ti ❑ LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) r7EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J (Sg fl�['"II FOR OEfALS) <br /> o O ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Lu <br /> wa F7 CONTAINMENT BARRIER(CB) El <br /> ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> s ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> ���rn <br /> LLJac�c�c-}��a-Q s ss ss Cw�l �%e� c�c,�J <br /> 0 R <br /> U <br /> HSC 05(&W <br />