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UNDERGROUND STORAGE TANK (UST) SITE - UNAUTHORIZED RELEASE If CONTAMINATION REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ Yes 0 REPORT BEEN FILED? ❑ Yes ❑ No I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25100.7 OF <br /> REPORT DATE CASE # THE HEALTH AND SAFETY CODE. <br /> _ / 7 _ / S SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> REPRESENTING COMPANY OR AGENCY NAME <br /> k' LOCALAGENCY ❑ REGIONAL ROARD �:I <br /> 0 El El // <br /> K OWNER/OPERATOR OTHER �ti — �¢3q = ulV,,� — T C oAa .¢.- <br /> e ' I1 <br /> A f <br /> ADDRESS /� <br /> STREET C= �` �"Q /�f A� ✓ �— CITY '� / ✓G</G J,�� STATECA ZIP <br /> Ila NAME CONTACTPERSON PHONE <br /> r <br /> m e'7 (•• '•• I W anT T , ❑ Unknown nL, <br /> � a ADDRESS 2 ) � <br /> ( / 1 STREET .}h� iL� 1E✓ CIN �= STAT2—/+Z ZIP <br /> FACILITY NAME (IF//APPLICABLE) OPERATOR PHONE <br /> a ADDRESSJJ� �� <br /> of � � / STREET CITY �T�tT.. COUNTY `pec-�� �+— ZIP <br /> m CROSSSTREEI' <br /> LOCALAGENCY AGENCY NAME PHONE <br /> 0 <br /> REGIONAL BOARD PHONE <br /> a <br /> (1 ) NAME QUANTITY LOST (GALLONS) <br /> Wo <br /> 0 - Uv Unknown <br /> ¢ ? Q Alio <br /> r o (Z) <br /> ❑ Unknown <br /> DATE DISCOVERED <br /> HOW DISCOVERED ❑ Tank Test ❑ Tank Removal ❑ Nuisance Conditions <br /> w _ ! 6 f hS w f-h -.—, ❑ Inventory Control ❑ Subsurface MonitoringUer <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THA APPLY) <br /> g ❑ Remove Contents �y,__lose Tank <br /> �L <br /> �Ly Unknown ❑ RepairTank F-1 Change Procedure <br /> HAS DISCHARGE BEEN STOPPED? ❑ Replace Tank ❑ Other <br /> Yes ❑ No IF YES, DATE (/ / 6 ? ❑ Repair Piping <br /> m SOURCE OF DISCHARGE CAUSE(S) <br /> ow <br /> m ¢ Tank ❑ Piping ❑ Dispenser ❑ Delivery Problem [] Spill ❑ Overfill ❑ Physical/Mechanical Damage ❑ Corrosion <br /> cc ❑ Submersible Turbine Pump (STP) ❑ Other ❑ Installation Problem r&I Unknown ❑ Other <br /> CHECK ONE ONLY <br /> a Undetermined ❑ Soil Only [] Groundwater ❑ Drinking Water — (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) '.. <br /> CHECK ONE ONLY '.. <br /> w +Open - Site Assessment ❑ Open - Verification Monitoring ' <br /> ( j F <br /> El Open - Assessment & Interim Remedial Action ❑ Open - Inactive <br /> ❑ Open - Remediation ❑ Closed — No Further Action Required <br /> CHECKAPPROPRIATE ACTION(S) <br /> FHuman health exposure control? [] Yes ❑ No • Unknown <br /> a Groundwater migration control? ❑ Yes ❑ No Unknown <br /> o ❑ No Action Required (NAR) ❑ Excavate & Treat (ET) ❑ Treatment at Hookup (TH) ❑ Other <br /> ❑ Excavate & Dispose (ED) ❑ Free Product Removal (FPR) ❑ Replace Supply (RS) <br /> z <br /> 0 <br /> 0 <br /> SWRCB Leak Report Form http://ivww.sNvrcb,ca.gov/ivater_issues/programs/ust/forms/ Rev. 02/012012 <br />