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I ` <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES NO REPORT BEEN FILED 7 ❑ YES ❑ NO 1 HEREBY CERTIFYTHAT.i;HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE WSTR CTION SIJEETONTHEBACK PAGE OF THIS FORM.: <br /> REPORT DATE CASE s f Z <br /> t MI Z'I S q � Y >S N DATE.. <br /> NAME OF INDIVIDUAL FILING REPORT PHONESI NATURE <br /> ca 3E'�Ry �(oSHioKA ( �)�1(aa 2-120 l2 <br /> I b <br /> w REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> p LOCAL AGENCY ❑ OTHER <br /> m ADDRESS <br /> Y44-5 N. Swn SoaL�ui�.t� S-}-r�C.�C�oh C pn� gSZ.O <br /> STREET Cm STATE ZIP <br /> w NAME CONTACTPERSON PHONE <br /> zQ ❑ UNKNOWN <br /> a< ADDRESS <br /> LLI <br /> 13q C� W til low Pass jkm d Coy c ov�� C� <br /> R cSTATE 1P iP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o �\nC� S,'t-a..-��o� i�L\k sorb (?D ) <br /> U ADDRESS � gSIZ.�s <br /> g t�3\5 �lcL�c�r�oo Road S-Eock.t'o•� Sw...10 ...��.. <br /> w STREET cm COUNTY <br /> CROSS STREET <br /> RR <br /> O LOCAL AGENCY' AGENCY NAME CONTACT PERSON PHONE <br /> z <br /> Uzi V FAA-L 1kroV_ c C. CJS OvL_ ) <br /> w w REGIONAL BOARD PHONE <br /> a.a.a W CEl ) <br /> u) NAME QUANTITY LOST(GALLONS) <br /> LU Lu <br /> oUNKNOWN <br /> a> <br /> m° (Z) <br /> Z <br /> N <br /> UNKNOWN <br /> z DATE DISCOVERED ��s Q , 1 HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> ui F ` MI ZMI ©�3 D) `r 4 Y ❑ TANK TEST ® TANK REMOVAL ❑ OTHER <br /> m <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> Q UNKNOWN F7 REMOVE CONTENTS CLOSE TANK&REMOVE Q REPAIR PIPING <br /> w M D Y Y pQ <br /> 00 HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK b FILL IN PLACE ❑CHANGE PROCEDURE <br /> YES ❑ NO IF YES.DATE I MI Z MI O DI Ck Yl'i r REPLACE TANK ❑OTHER <br /> 0 <br /> • SOURCE OF DISCHARGE CAUSE(S) <br /> D c f7TANK LEAK UNKNOWN Q OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> U)O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> Lu V) <br /> wa CHECK ONE ONLY <br /> v UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z ❑ NO ACTION TAKEN F7PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> cr y LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> V ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> (SEE SACK FOR OETARA <br /> a ZE5 0 ❑ CAP SITE(CO) ❑ EXCAVATE E TREAT(ET) ❑ PUMPS TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w <br /> w� <br /> w c ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> m 8 <br /> HSC 0510) <br />