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i <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I 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 1HEREP CER71FYTHAT 1 HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEETON THE BACK PAGE OFTHIS FORM. <br /> REPORT DATE CASE 8 ' <br /> nmLu J O SIGNED DATE <br /> NAME OF INDIVIDUAL FILING EPORT PHONE SIGNATURE <br /> I m <br /> w REPRESENTING �- RroPERATOR ❑ REGIONAL.BOARD COMPj�NY OR AGENCY NAME <br /> 5`{rl�, , <br /> ¢ ❑ LOCALAGENCY ClOTHER <br /> r8h� USR <br />' Q ADDRESS !/r�()))/�1'J� <br /> 9TRElT V— _ GiTY Jr 7 STATE ( 21P <br /> 1 CONTACT PERSON (PHONE <br /> owo NAME ❑UNKNOWN ` � •�� <br />' w IE S <br /> Z <br /> �a ADDRESS <br /> �a <br /> LLr <br /> 2 $TREIT CRY STATE i 1V P <br /> FACILITY N ELF APPLICABLE) OPERATOR PHONE <br />' Z w <br /> q ADDRESS �J}- ( Ji+��} ��J L Q% ��/j <br /> 0 3 f-af V� j REEY ! ! LffY V♦✓i�L �'�%wc,OVHTY • J P <br />' y Ll <br /> CROSS 3TREE� <br /> c] <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> S V\ J (h cooll\v, F-v�v'ro� k4► 1)=v <br /> �++v PHONE <br /> Lu REGIONAL BDARD <br /> Ce - RW6LCJ3 SRI ?255-3� <br />' {t) NAME QUANTITY LOST(GALLONS) <br /> y� p NKNOWN <br /> uJ <br /> w <br /> Z <br /> 9 �UNKNOWN <br /> y z -rem-a,A 1 ,� e���t <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> ui <br /> z n D r ❑ TANK TEST E:] TANK REMOVAL ❑ OTHER <br />' DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> } UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> 01 YL A <br /> Lu <br /> HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br />' a ❑ YES ❑ NO IF YES DATE r r ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSES) <br /> Eo <br /> ❑ TANK LEAK UNKNOWN F7 OVERFILL ❑ RUPTURFJFAILURE ❑ SPILL <br />' 'o U ❑ P1P1NG LEAK ❑ OTHER ❑ CORROSION VNKNOWN F-1 OTHER <br /> I <br /> w w CHECK ONE ONLY <br /> U?� ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />' CHECKONEONLY <br /> I-0 <br /> ❑ NO ACTION TAKEN F-1PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMRTED E::] POLLUTION CHARACTERIZATION <br /> LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />' Urn ❑ REMEDIATION PLAN ❑ CASE CLOSED(=ANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE d DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BID DEGRADATION(IT) <br /> 1SEE she RM DUARM <br /> a z ❑ CAP SITE M ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY{RS) <br />' w VENT SOIL(VS) <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REOUIR (NA) ❑ TREATMENT AT KU (HU) <br /> ❑ VACUUM EXTRACT(VE)cc OTHER(OT) <br /> sa�:� "�" r ULV !!�v/fJ" <br />' m r+ <br /> z <br /> H9C 05 famo <br />