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--+) YY <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/,,CONTAMINATION SITE REPORT <br /> I <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? HEREBY,CERTIFYTHAT 3,HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ YES �NO ❑ YES NO l <br /> DISTR IPUT15 SHOWN CUT E INSTRUCTON SHEEf.ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE CASE s <br /> r I MI LAI 0 Y HED...r':'- -:-OATE, <br /> NAMEOF INDWIDUAL FILING REPORT PHONE -� SIG NATU E <br /> w REPRESENTING OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGEN AME <br /> I�I L AL AGENCY OTHER <br /> ADDRESS <br /> STATE <br /> STREET Cfll' �' 21P <br /> w NAMED �CONTACT PERSON i" 1P ACNE 1 r <br /> Fn �f-'f�s/ ��LY ❑ UNKNOWNco <br /> aaA j�' ids .' <br /> Oa a ADDRESS iR <br /> 5 EET CITY ! STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR /PHONE }} <br /> _o <br /> ~ ADDRESS / <br /> Lu Lu R CITY 4, COUNTY ZIP <br /> t= CROSS STREET <br /> cn <br /> { !A <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> W <br /> W U <br /> w w REGIONAL BOARD !PHONE }} <br /> a¢ 1 1 <br /> w (1) NAME /j QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> �J <br /> m o (Z) <br /> D <br /> �� ❑ UNKNOWN <br /> z Z DATE DISCOVERED G� HOW DISCOVERED ❑ INVENTORYCQNTROL ❑ SUMURFACE MONITORING NUISANCE CONDITIONS <br /> E-1w Mlz MI D aI D /Y Y ❑ TANK TEST TANK REMOVAL � OTHER <br /> ¢ DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE REPAIR PIPING <br /> ui M l D D Y Y <br /> O HAS DISCHARGE BEEN STOPPED T ❑REPAIR TANK I!R CLOSE TANK&FILL IN PLACE O CHANGE PROCEDURE <br /> ± O ❑ YES NO IF YES,DAN ❑REPLACE TANK OTHER <br /> MI o I v <br /> SOURCE OF DISCHARGE CAUSES) J <br /> LED TANK LEAK UNKNOWN ❑ OVERFILL Rf1PTUREfFAILURE ❑ SPILL I <br /> y O ❑ PIPING LEAK ❑ OTHER CORROSION UNKNOWN OTHER <br /> aa CHECK ONE ONLY <br /> ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY j <br /> NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> � <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 BIO DEGRADATION{IT) <br /> fSM BACK FSR OCT,LLS] .P <br /> C z 1 <br /> o O ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP 8 TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> �' ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REOUIRED{NA) TREATMENT AT HOOKUP(HU) � VENT SOIL(VS) <br /> r <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> Tia •x.45 Qv,2/ �"+¢' /�F ' � s2F�ic71.s�L [� / / <br /> 0 <br /> 0 <br /> f HSC x518+901 I <br />