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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? <br /> ❑ YES NO ❑ YES NO 1 HEREBY CERTIFYTHAT(HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> IJlS. UTIONOWN STRU TION SHEETON THE BA PAGE OF THIS FORM. <br /> REPORT DATE CASEx <br /> 1M 7 / y SIGNED �l <br /> DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE - <br /> �� Ma ewA c �6 3 s �� <br /> 0 <br /> w REPRESENTING ❑ OWN£RlOPERATOR ❑ REGIONAL BOARD COMPANYORAGENCY NAME /1 <br /> Q LOCAL AGENCY ❑ OTHER <br /> ¢ ADDDDRR�E,S 9t-� l <br /> ATE <br /> J NAME CONTACTPERSON PHONE <br /> m <br /> zQ <br /> ❑ UNKNOWN <br /> o< <br /> ADDRESS ��////J /y� 7► <br /> FACILITY NAME(IF APPLICABLE) OPERAT PHONE <br /> , - 364,c4n1t1 <br /> ¢ ADDRESS <br /> STREET V r CRYWy s� <br /> � <br /> CROSS STREET <br /> IP <br /> cry LOCAL AGENCY AGENCY NAME CO CT PERSON <br /> PHONEw <br /> w� J- Ps /amu c 3s' <br /> w <br /> U <br /> Z REGIONAL BOARD <br /> PHONE <br /> w w( T) NAME QUANTITY LOST(GALLONS) <br /> F a 0 `� �+"+�C SE��//F;/� UNKNOWN <br /> co a (zl <br /> ❑ UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED <br /> w / ❑ INVENTORY CONTROL SUBSURFACE MONITORING E:] NUISANCE CONDITIONS <br /> w -MI M oI t o v y E:] TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M D o y y ©UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> O HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK E TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> `n YES NO IF YES,DATE ❑w�OT <br /> ❑ ❑ ❑REPLACE TANK R <br /> M MID � y y <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> c ❑ TANK LEAK -KNOWN ❑ OVERFILL ❑ RUPTUREJFAILURE ❑ SPILL <br /> c O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> U)fL CHEMONLY <br /> v TERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK O E ONLY <br /> z� <br /> 2 NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED E7] POLLUTION CHARACTERIZATION <br /> w <br /> cc vii ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> (SEE s FM DETM.S) <br /> a <br /> a 0 ❑ CAP SITE(CO) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> < ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑� OTHER(OT) <br /> Z <br /> �� <br /> Lu <br /> 0 <br /> U <br /> HSL 45(A'gq <br />