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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 <br /> ❑ F7,, NO REPORT BEEN FILED 7 ❑ YES ❑ NO 1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM: <br /> REPORT DATE CASE ar <br /> M M SIGNED DATE <br /> NAME OF NOIVIDUAL FILING REP91RY PHONE SIGNATURE <br /> > <br /> m <br /> REPRESENTING'— F-1 OWNE BATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> p ❑ LOCALAGENCY ❑ OTHER <br /> ADDRESS <br /> • RE, i �C.60:1C STATE <br /> J NAME/ i 7 i CONTACT PERSON PHONE <br /> zUNKNOWN <br /> a Qa �k�DD81ESS <br /> V) <br /> ¢ <br /> GTY `/ fSTATE <br /> FACILITY NAME(IF APPLI BLE) OPERATOR PHONE <br /> o_ L' / <br /> < ADD <br /> a <br /> w <br /> ~ <br /> CRO!§S STREET <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> zW <br /> z w <br /> U <br /> w w REGIONAL BOARD PHONE <br /> J C7 <br /> a a r ) <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> wp <br /> U w <br /> a J ❑ UNKNOWN <br /> D <br /> z (Z) <br /> U ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SU URFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lu <br /> I dMI M o go y Y ❑ TANK TEST ❑ TANK REMOVAL OTHER <br /> METHOD USED TO STOP <br /> m DATE DISCHARGE BEGAN ❑ UNKNOWN ❑REMOVE CONTENTS DISCHARGE <br /> TANK &REMOVE APPLY) EPAIR PIPING <br /> a <br /> w cw M D Y <br /> >O HAS DISCHARGE BEEN STOPPED Z E:]REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> `) ❑ YES ❑ NO IF YES.DATE ❑REPLACE TANK ❑ OTHER <br /> p M MI D d V Y <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> Lu <br /> ¢U ❑ TANK LEAK F-1UNKNOWN F-] OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> 7 Q <br /> cn U PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w nw. CHECK ONE ONLY <br /> U ❑ 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 /> D ami F-] LEAK BEING CONFIRMED F7 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 SACK FOR DETA S) <br /> a Z ❑ <br /> p0 CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)E:] REPLACE SUPPLY(RS) <br /> w� <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED JNA) ❑ TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> ¢ ❑ VACUUM EXTRACT(VE) E2"-OTHER(OT) <br /> v <br /> z <br /> z <br /> w <br /> O <br /> U <br /> HSC 05(a90) <br />