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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICE FOii LOCAL AGENCY USE ONI:Y <br /> ❑ YES MNO REPORT BEEN FILED i <br /> ❑ YES NO 1 HEREBY CEATIFYTHAT)HAVE RI$TR(BUTEpSHiS 3NFQRMATtONl4CCOROtIVG TOTHE <br /> CASE s WSTFiUCTION <br /> REPORT DATE SHEET ON THE BACK PAGE OF.THIS FORM <br /> DISTAI9UTIDN SHOWN <br /> ON.,THE <br /> M u 0 y _SIGNED �; - <br /> NAME OF INDIVIDUAL FILING R PORT <br /> PHONE StGNATUR <br /> ccl doh L v\ c z LUl � -��� . <br /> REPRESENT G ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAM <br /> LOCAL AGENCY ❑ OTHEA [G V,4 1i <br /> w u AooREss4 Pi 'GU Pi �¢ <br /> � <br /> STRMtr , We cmSTATE <br /> GG <br /> m <br /> NAME CONTACTPERSON PHONE IIP <br /> z l� /AUC/� ❑ UNKNOWN <br /> yas ADDRESS <br /> cc <br /> STREET <br /> �� p] <br /> CrTY �(rY7 STATE tip/�GG <br /> FACILI NAME(IF APPLICABLE) OPERATOR PHONE <br /> Z `�Z 3 <br /> 0 <br /> ~ ADDRESS i <br /> U /�fJ / C/ <br /> W /v STREET erry <br /> \ ^T/+ / eo <br /> y CROSS STREET COU�+TI -J J l� Zip L <br /> e <br /> cl z LOCAL AGENCY AGENCY NAME CDNTACTPERSON <br /> z w PHONE <br /> w_ <br /> w U <br /> w w REGIONAL BOARD PHONE <br /> CL a / 11 <br /> � \ J <br /> S ' <br /> uj <br /> S ) NAME i QUANTITY LOST(GALLONS) <br /> Lu <br /> r0 4p-'L�7. � 3NKNOWN O <br /> rn <br /> m z C11 i <br /> ❑ UNKNOWN <br /> 4 I <br /> FDATE DISCOVERED <br /> w NOW DISCOVERED <br /> ❑ INVENTORY CONTROL 0 SUBSURFACE MONITORING ❑ NUISANCE CQNOITIONS <br /> TANK TEST TANK REMOVAL THERw O Llj <br /> 4 DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) _ O <br /> w �+ o Y r UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK b REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED i ❑REPAIR TANK ❑CLOSE TANK L FILL IN PLACE ❑CHANGE PROCEOURc <br /> ❑ YES ❑ NO IF YES.DATE uI D y y ❑REPLACE TANK ❑ OTHER <br /> SOUR DISCHARGE CAUSE(S) <br /> a TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL J r , A <br /> y v [:j PIPING LEAK 0 OTHER ❑ CORROSION ❑ UNKNOWN Q OTHER 6CitTFC.Y 4JiAl <br /> CA wQ CHECKONEONLY <br /> U ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK QNE ONLY <br /> w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> jH ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE d DISPOSE(ED) REMOVE FREE PRODUCT(FP) ❑ ENHANCED 910 DEGRADATION(IT) <br /> 1XEWe EarsOETA" <br /> Z <br /> 0 CAP SITE(CD) ❑ EXCAVATE d TREAT(IM ❑ PUMP 3 TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> L a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTK)N REOUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT)Lu <br /> lien <br /> Gel. T.�-f �-...� i•�-,�•� y/z/�r , . <br /> $ caC/o ssz�g8� <br /> HSC 05 <br /> 16'9x'1 <br />