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s . <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED ? ❑ YES NO 1HERE CERTIFYTHATI HAVE DISTRIBUTED THIS INFORMATION CORDING TOTHE <br /> ❑ VES NO <br /> DIST UTIONS NON ISTA TION SF�EET ON THE BACI P EOF THIS FORM <br /> REPO RJ�Tj(,�)ATE/j�/ 9 CASE # i✓ki..�l_ +�✓/^� ✓�j C <br /> DM (J u ` ' 5 / V SIGNED DATE <br /> NNAg OF INDIVIDUAL FI ING REPORT PHONE GNATU <br /> ic,�i9E /NF/.C /2iV 693 S <br /> w REPRES TING F-1OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> p LOCALAGENCY ❑ OTHER f}�S <br /> ADDRESS ///� . //� <br /> /?or Y00 STREET CRY S%PyAl STATE <br /> NAMES n^ P � � � T� CO TnCT PERSON <br /> PHOPE <br /> N �Q �L� / (•[i( CSO - ❑ 2 UNKNOWN /C . .�� ( JI • ��3J <br /> n < ADDRESS (//��� /J /T/� /, <br /> • B 5�' // STREET CIT",-�^�n /+V{.C� V STATE Zip <br /> FACIMIf(IF AP LICABLE) OPERATOR PHONE <br /> 0 <br /> ADDRESS <br /> U 0 J'^ <br /> DO �q 6 <br /> STREET (,� - � COUNTY inG <br /> CROSS STREET G <br /> G <br /> AIAwlv <br /> 0 LOCALAGENCY AGENCY E CONTACT PERSON PHONE <br /> Zy �" Co . fi4�s M . irvFu ,en,A Qo9 ) 65.3 s <br /> ww <br /> w9 REGIONAL BOAR PHONE <br /> ( 1I <br /> w (1) ra <br /> NAME ��] QUANTITY LOST (GALLONS) <br /> = W /aD3 /S G` A 7VIC Yi�sfi '�L Cv� <br /> F O UNKNOWN <br /> N i (2) <br /> � ❑ UNKNOWN <br /> Q" r DATE DISCOVERED Q HOW DISCOVERED ❑ INVENTOflY CONTROL SUBSURFACE MONITORING E] NUISANCE CONDITIONS <br /> w VM V M �D SDI ( Y / Y ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> dUNKNOWN ❑ REMOVE CONTENTS ❑ CLOSE TANK & REMOVE ❑ REPAIR PIPING <br /> M M D D Y Y <br /> p HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE <br /> 5 ❑ VES NO IFYES, DATE M M 01 d yl Y ❑ REPLACE TANK ❑ OTHER <br /> w SOURCE OF DISCHARGE CAUSE(S) <br /> ¢ j ❑ TANKLEAK UNKNOWN ❑ OVERFILL PTURE/FAILURE ❑ SPILL <br /> w O O PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN 0 OTHER <br /> ww CHECKONEONLY <br /> O Z ❑ UNDETERMINED OIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wM F-] NOACTIONTAKENRMED {P❑ RELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED E::] POLLUTION CHARACTERIZATION <br /> r ❑ LEAK BEING CONFIRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> Uy ❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK ATE APPROPRITACTION(S) ❑ EXCAVATE 8 DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ENHANCED BIO DEGRADATION (IT) <br /> Z (sePRO R ATE sI <br /> O 0 ❑ CAP SITE (CD) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br /> M U ❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED INA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br /> w < <br /> ❑ VACUUM EXTRACT (VE) ❑ OTHER (OT) <br /> y- <br /> E <br /> a <br /> U <br /> HSC 0 (MO) <br />