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z� <br /> sr <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERG CY SERVICES :FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 <br /> ❑ YES No YES ❑ NO 1HEREBY.CERT(FYTHAT1.HAVE DISTRIBUTED THIS INFORMATIOiVACCORDING TOTHE <br /> DISTRIBUTION SHOWN CN THE INSTBLLCTION SHEET ON IHE BACK PAGE OF THIS FORM <br /> RCASE t <br /> REPORT DATE I <br /> ' <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE DATE <br /> } c-4, oti) q6 f-3 v r <br /> m w <br /> Lu REPRES ING ❑ OWNER/OPERATpR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> oLOCAL AGENCY ❑ OTHER C ]� r <br /> Lu <br /> cc ADDR S n <br /> J�0 G �J <br /> ClpS7/v}/ti1/ ( S�ooff�, C/9 �5ao� <br /> srRe�T cm STATE ZIP <br /> w NAME CONT TPERSON PHONE <br /> f s G? <br /> zQ 1 ❑ UNKNOWN Y�� <br /> CL <br /> a ADDRESS <br /> w <br /> m ,, tti777SSYSTATE 6 <br /> x <br /> STREET <br /> FACILITY NAME(IF APPLK; E) OPERATOR PHONE <br /> 0 S 1/07 <br /> 0 ADDRESS D I D JA / G0i v" - <br /> STREET CITY COUP. p <br /> y CROSS STREET <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> W(J <br /> S - <br /> w REGK)NAL BOARp PHONE <br /> a< {t1�C)\ 1w\ <br /> LU (S) �e/ a NAME QUANTITY LOST[GALLOIfS} <br /> WAe <br /> a� UNKNOWN <br /> `r'L, UNKNOWN <br /> z DATEII DISCOVERED W DISCOVERED 11INV NTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lu <br /> w wN M n r r ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> r <br /> 4 DATE DISCHARGE BEGAN METRO SED TO STOP DISCHAR (CHECK ALL THAT APPLY) <br /> cc <br /> UNKNOWN REMOVE CONTENTS CLOSE TANK 5 REMOVE ❑REPAIR PIPING <br /> Lu D D Y <br /> HAS pIS RGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK 5 FILL IN PLACE ❑CHANGE PROCEDURE <br /> U Q I <br /> N YES ❑ NO IFYES.DATE 1 I �� I ( I ❑REPLACE TANK ❑OTHER <br /> M D Y Y <br /> U, <br /> SOURCE DISCHARGE CAUSES) <br /> L)j TANK LEAK ❑ UNKNOWN OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> m v ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> m L. CHECK ONE ONLY <br /> a <br /> o ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER •(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ❑ NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> uiui <br /> C', F-1LEAKBEING 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 3 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ISM SACK FM OffMAg <br /> a Z <br /> w0 ❑ CAP SITE(co) ❑ EXCAVATE d TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Lu a F7 CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> Lu <br /> Vt <br /> U w <br /> O � `ie� ra HSC <br />