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I <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 <br /> ❑ YES NO ❑ YES ❑ NO IHEREBY.CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DIS IBUTION SHOWN ON TH RU TINSTION SHEET ON THE BACK P/fAGE OF THIS <br /> 116 <br /> FORM <br /> REPORT <br /> 1DATE C\ CASEQ� � -f <br /> Sr SIG ED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIG IjkTURE <br /> ca Li <br /> w REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> p LOCAL AGENCY ❑ OTHER S(Lvx; ( (,(,�1�(d, .��z t- .6 (.+k �oces <br /> cr ADDRESS �� <br /> S7AT <br /> Ci v STREET' ' 1 1 �C/� E <br /> ZIP <br /> w NAME CONTACT PERSON ^ PHONE <br /> z �� V� �`-G .i 1G�C� ❑ UNKNOWN <br /> 0 a ADDRESS <br /> cc C5 <br /> STREET CITY STATE Zlp <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE / <br /> ADDRESS <br /> �1 � e I�GI� Sic�Z�rml <br /> CITY COUNTY ZIP <br /> ~ CROSS STREET <br /> 1� c,c) <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z(n <br /> W s�:i R��I � Unv. r�W4�). (-oma <br /> Lu O a "v. <br /> w w REGIONAL BOARD PHONE <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> LU <br /> a w 6 aSC� < fie UNKNOWN <br /> m z (2) <br /> � <br /> ❑ UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING RING ❑ NUISANCE CONDITIONS <br /> Iv- Y ❑ TANK TEST ❑ TANK REMOVAL OTHER Sp <br /> O(t rj0Y` <br /> FId <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> cc <br /> UNKNOWN ❑REMOVE CONTENTS 1�5CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> w M M D D Y Y <br /> p rHAS DISCHARGE BEEN STOPPED 7 (,.,,�u�l� ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> c YES ❑ NO IF YES,DATE <br /> M MI ! Y <br /> V D ❑REPLACE TANK ❑ OTHER <br /> D <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> ❑ TANK LEAK XfUNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> U)O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> W w CHECK ONE ONLY <br /> cn a <br /> L) ❑ 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 /> ❑ 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) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> J (SEE BACK FON ME ACS) <br /> o p ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> cr ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> z S''-�e �h� �� PlcCe�� cc-� C Ue��� �� rn <br /> 0 <br /> c�cncR-Q s�-� <br /> U <br /> HSC 05(a90) <br />