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Z/ - MCD <br /> UNDERGROUND ST AGE TANK UNA OR (LEA 1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY { - <br /> REPORT BEEN FILED 7 <br /> El �:-,/YES No YES �o ,i HEREHYCERTIFYIFIATi'HAVEbidAIBIITE[]THISINFORMATIONACCORDING TOTHE, <br /> q TIOD!SH td ON THEIN SHEET ON THE BACK PAGE OF IS <br /> REPORT DATE CASE R <br /> rya <br /> u A uI :SIGMF�. :... ::i .. ....... a1 E.:: <br /> NAME OF INDIVIDUAL FILING REPORT PHONE Sl RE 4) ac_C_ tai)�� -3�4�z ` <br /> w REPRESENTING ❑ OWNERIOPERATOR ❑ ,REGIONAL BOARD COMPANY OR AGENCY NAME <br /> 2 R LOCAL AGENCY D OTHER <br /> ADDRESS <br /> N ME <br /> CONTACT PERSON PHONE <br /> J r^ f <br /> z t.�/ ❑UNKNOWN <br /> s <br /> a aa. ADDRESS <br /> 3-333 <br /> REECLQ <br /> p <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE O <br /> ADDRESS _ <br /> W s'/fib ��c STMT CITY C013 P <br /> H CROSS SfT�REEiET <br /> O L A AGENCY AGENCY.%WF CONTACT PERSON PHONE <br /> U3 /q7 <br /> L�u w REGION OARD PHONE <br /> CL LVI�� �• l t ? <br /> w (I) NAME QUANTITY LOST(GALLO S) <br /> d <br /> Z J � UNKNOWN <br /> m O (2) <br /> y 2 <br /> C�rUNKNOWN <br /> z DATE DISCOVERED I HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING F-1NUISANCE CONDITIONS <br /> LU <br /> w D u) u� �-4I r r C:] ,ANK TEST [:] TANK REMOVAL OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT AP LY) <br /> a <br /> UNKNOWN REMOVE CONTENTS [P�CLOSE TANK h REMOVE ❑UPAIR PIPING <br /> IL M D Y Y <br /> 111 <br /> 00 HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> w YES NO IF YES,DATE I F ❑REPLACE.TANK OTHER <br /> O M Y Y Y <br /> �Lj SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANK LEAK UNKNOW?! ❑ OVERFILL PA PTURElFAILURE SPILL <br /> yUPIPING LEAK OTHER ❑ CORROSION KNOWN OTHER <br /> m a CHECK E ONLY <br /> U UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z NO ACTION TAKEN F7PRELAIINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> s <br /> ❑ LEAK BEING CONFIRMED ❑ PR9-NiNARY 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) ❑ ](CAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J BACK FM 0om-q) . <br /> a o CAA SITE(CD) ❑ EXCAVATE 8 TREAT(ET) PUMPS TREAT GROUNDWATER(GT) REPLACE SUPPLY(RSI <br /> tu <br /> wL) <br /> ❑ CONTAINMENT BARRIER(C8) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ CTHER(OT) <br /> w <br /> HSC OS ill <br />