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i <br /> i <br /> n <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> N EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES % FOR LOCAL AGENCY:USE ONLY <br /> REPORT BEEN FILED 7 <br /> '� ❑ <br /> YES NO ❑ YEs MIND 1HERERY CERTITY7HAT1 HAVE DISTRIBUTED THIS INFORMATION ACCORDING fOTHE <br /> DISTRIBUTION S I HOWNA THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE CASE <br /> Mb M y r o <br /> ATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> wREPRESENTING ❑ OWNERNPERATOfl ❑ REGIONALROARD COMPANY OR AGENCY NAME <br /> p LOCAL AGENCY ❑ OTHER SSC c L l h <br /> US ADDRESS <br /> 6Ob F7 , M STATE 06 vtek C4 N1 ZIP <br /> NAME <br /> Pen <br /> /'lS1rRE�Er ^`r CONTACTPEHSON PHONE (�� � / �y <br /> w ¢ L <J7 { ) N PeiU 6 ,T' + v 11" uLj UNKNOWN kLV v (�OO � CJ•( % fj <br /> a < ADDRESS <br /> 36 0t t w (Tob 0� 4 S Joss. e� cila2 <br /> crry srn <br /> FACILITY NAME (IF APPLICABLE) sT OPERATOR PHONE <br /> A-L AA 1r L/O <br /> ADDRESS <br /> STREET clw cOUNTy ZIP <br /> ' — CROSS STREET <br /> O LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> F O REGIONAL BOARD PHONE <br /> w (1) NAME (� QUANTITY LOST (GALLONS) <br /> r o TD I'�' )6y tue A - `� rJ fbY Lo .JCA ZLMi TO I U G � UNKNOWN <br /> y o (2) <br /> Lltr- Dk4�j I4J% TP t COASQ ( ( 'SQ -/ 15kL UNKNOWN <br /> I- GATE DISCOVERED HOW DISCOVERED ❑ INVENTORYCONTROLSUBSURFACEMONITORING ❑ NUISANCE CONDITIONS <br /> MI MI of !/ of y ❑ TANK TEST ❑ TANK REMOVAL x OTHER ( G Ter V <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> M M o y y UNKNOWN ❑ REMOVE CONTENTS CLOSE TANKS REMOVE ❑ REPAIR PIPING <br /> 8 HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIR TANK CLOSE TANK 8 FILL IN PUKE ❑ CHANGE PROCEDURE <br /> YES El No IFYES, DATE M O Mi 0.1 ,7 -1 1 YlA y ❑ REPLACE TANK ❑ OTHER <br /> O SOURCE OF DISCHARGE CAUSE(S) - <br /> ¢ `^ TANK LEAK ❑ UNKNOWN ❑ OVERFILL RUPTURE/FAILURE ❑ SPILL <br /> wO PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> w CHECKONEONLY <br /> O ❑ UNDETERMINED SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> wz ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECKAPPPROPRIIATE ACTION(S) ❑ EXCAVATE & DISPOSE JED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <br /> 00 ❑ `CAP SITE (CD) O ❑ EXCAVATE & TREAT (ET) ❑ PUMPA TREAT GROUNDWATER (GT) REPLACE SUPPLY IRS) <br /> w < ❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) __ II❑ TREATMENT AT HOOKUP IHU ❑ VENT SOIL (VS) <br /> ❑ <br /> VACUUM EXTRACT (VE) OTHER (OT) Q Qraa � L (( UV <br /> w <br /> E <br /> f <br /> 0 <br /> U <br /> HsC os IH'oo) <br />