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L7 - v�y <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> REPORT BEEN FILED 7 FOR LOCAL"AGENCY USE ONLY <br /> ❑ YES NO YES ❑ NO 1HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMAT.I ACCORDING TO THE <br /> REPORT DATE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> CASE 9 ! <br /> l t� t <br /> SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> w <br /> REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> OXLOCAL AGENCY ❑ OTHER Si • P I"} — H b` <br /> ADDRESS <br /> STREET CTTY STATE ZIP 40, ��. <br /> J NAME CONTACT PERSON PHONE <br /> us.� <br /> `n ��,a ❑ UNKNOWN <br /> z¢ <br /> a a ADDRESS <br /> ca <br /> STREET CTTr STATE 71P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS 4 <br /> COUNTYZIP <br /> 7L <br /> CROSS STREET I <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> zco <br /> ui <br /> zS e6 <br /> �' <br /> w REGIONAL BOARD PHONE <br /> a. <br /> w (I) NA/M�E I QUANTITY LOST(GALLONS) <br /> O w <br /> Z J l_1 C. W'�'J /til Q CL." �,7�1^�: UNKNOWN <br /> Q <br /> H 0 <br /> m> (Z) <br /> mz <br /> y <br /> ❑ UNKNOWN <br /> Z DATE DISCOVERED �]_ HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lu <br /> w ®I.II r `-'r ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> Q DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> s M o r r -:24UNKNOWN REMOVE CONTENTS I XI CLOSE TANK a REMOVE ❑REPAIR PIPING <br /> w �� <br /> p HAS DISCHARGE BEEN STOPPED 76 <br /> ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> E5 YES ❑ NO IF YES,DATE O MI o [ v v ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ja ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> y V ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> Lu wa CHECK ONE ONLY <br /> O ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER E:] DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z 17[f NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED F7 POLLUTION CHARACTERIZATION <br /> a <br /> �� ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) 0 CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J (SEE BACK FOR MTAISI <br /> a z ❑ <br /> D O CAP SITE(CO) ❑ EXCAVATE&TREAT(ET) ❑ PUMP d TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> LU <br /> LuU <br /> Lu Q ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HUS ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> ca <br /> z <br /> Lu <br /> 412 4t4 q <br /> HSC 05(990) <br />