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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCYFOH LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 <br /> HAS STATE OFFICE OF EMERGENCY SERVICES i HEREBY CERT)FYTHAT 3.HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ YES NO [::] YES �NO <br /> 015TR1 UTION SHOWN ON THEENSTRUCTION SHEET ON THE BACK PAGE OF IS F M <br /> REPORT DATE CASE s {Q_ <br /> MI MI �'! rl r <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGN TUBE <br /> Y <br /> m <br /> REPRESENTING ❑ OWNERlOPERATOR ❑ REGIONAL 80AR0 COMPANY OR AGENCY NAME <br /> C5/ r <br /> p LOCAL AGENCY ❑ OTHER �,:� , b <br /> Q ADDRESS <br /> TIIFYSTREET STATE ���✓� �/P ' <br /> J N/AM�D CONTACT PERSON /PHONE <br /> z L'S1[. 'I/ �JI� C/ � UNKNOWN �z-,,/�\�� <br /> 0- <br /> CL 'c A RESSCL <br /> Jf <br /> CC �� 466 a <br /> ( <br /> W <br /> STREET CITY STATE 21P <br /> FACILITY NAME(IF APPLICABLE) ' ! OPERATOR PHONE �s <br /> a AD ` <br /> 10 / Lam ' LCOUNTY,�, L S.'A- Cly. <br /> J STREET CRY <br /> W D SS <br /> IP <br /> F CROSS STREET <br /> LOCAL AGE YNAME CONTACTPERSON PHONE G <br /> w _/ �� ( €- " �- � ( ` ) 6 -SYS <br /> w w REGIONAL BOARD I PHONE <br /> �O <br /> a Gv`2-c-.-lip L-3 �l��f,�, ,•-- 1Giz- )� -yl 35 <br /> y {5) NAME QUANTITY LOST(GALLONS) <br /> W O - <br /> f� <br /> v W Q UNKNOWN h <br /> Z <br /> ~° c <br /> y> <br /> m <br /> a UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING ED NUISANCE CONDITIONS <br /> z / 1 � <br /> Lu MI u 1. oI o! J vIS r ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> r- <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> � MI <br /> ol yl yl <br /> UNKNOWN REMOVE CONTENTS ❑CLOSE TANK d REMOVE ❑REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK d FILL IN PLACE [:]CHANGE PROCEDURE <br /> o YES ❑ NO IF YES,DATE Mk j o d rl y ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGECAUSES) <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ R PTURFJFAILURE ❑ SPILL <br /> W U PIPING LEAK F-1OTHER CORROSION UNKNOWN ❑ OTHER <br /> w w C EC E ONLY <br /> N!L <br /> U NOETERMINED ❑ SOIL ONLY UZ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHEC NE ONLY <br /> w NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBM)TfED ❑ POLLUTION CHARACTERIZATION <br /> 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 ACTIONS) Q EXCAVATE d DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J IsEE SW1 K r DUAISI <br /> a z CAP SITE(CO) ❑ EXCAVATE d TREAT(ET) ❑ PUMP d TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ui <br /> d O <br /> w a CONTAINMENT BARRIER(CS) ElNO ACTION REQUIRED(NA) F-1TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) F--j OTHER(OT) <br /> n <br /> Lu <br /> Lu <br /> O <br /> U <br /> HSC 051&" <br />