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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> FOR LOCAL AGENCY USE.ONLY <br /> REPORT BEEN FILED 7 1 HERESY CERTIFYTHAT 1 HAVE.DISTRIBUTE.D THIS INFORMATION ACCORDING TO THE:: <br /> 0 YES NO O YES Q NO <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE SACK PAGE OF THIS FORM <br /> REPORT DATE CASE>< <br /> O M M oZ ' O O r SIGNEb DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> >m (,o R pvivc.4N Qcq N69031-4- <br /> w REPRESENTING O OWNER/OPERATOR Q REGIONAL BOARD COMPANY O)R AGENCY NAME �G <br /> LOCAL AGENCY 0 OTHER SQ V <br /> h Oq v IM-cc <br /> ADDRESS �/j��}(� G ' —{/ <br /> 3 v �' _3TREEr ' S 1 G � STATE�I , P <br /> Lu NAME /- 'AA ,, CONTACTPE`R�S�OuN�� PHONE J� <br /> zYv�l V D UNKNOWN 7w���1 (Q� SCJ <br /> o¢ <br /> 0-Qa ADDRESS / <br /> Lu C6 2-01y (a 11 A k- t,) —e cm L�t1 STATE O//�'' �ZIP CJ <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> 0 <br /> UADDRESS <br /> -5-94 ) <br /> J <br /> 7l 1Vl / C• �Y' C cou�� <br /> W <br /> N CROSS STREET l^ Lei <br /> ,_ ^ <br /> mak <br /> a LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z 5 - v t..a&\wv,4v t 4mt-I-, Lori DU Kce% �-- Y68'0.33 7 p <br /> w w REGIONAL BOARD PHONE <br /> Ce,�vo.l �/u GI ►M. .tel/ ( � � <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> Lu <br /> z j 1 UNKNOWN <br /> la--J <br /> m z (2) <br /> U) <br /> UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL O SUBSURFACE MONITORING a NUISANCE CONDITIONS <br /> ui <br /> I MI OMI oI o y y O TANK TEST Q TANK REMOVAL OTHER �^V t V-0 k M18t�1.�ot,(A-,SLySIN{bt'�` <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M or r IN <br /> UNKNOWN REMOVE CONTENTS a CLOSE TANK&REMOVE REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED? 0 REPAIR TANK O CLOSE TANK&FILL IN PLACE E:j CHANGE PROCEDURE <br /> U <br /> o a YES 0 NO IF YES,DATE M MI DI yl y Q REPLACE TANK 0 OTHER <br /> � SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> `j O TANK LEAK UNKNOWN F--j OVERFILL O RUPTURE/FAILURE 0 SPILL <br /> ti v 0 PIPING LEAK a OTHER a CORROSION UNKNOWN O OTHER <br /> W w CHECK ONE ONLY <br /> Cna <br /> OUNDETERMINED E::] SOIL ONLY GROUNDWATER 0 DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w O NO ACTION TAKEN 0 PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> h 0 LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> U Q REMEDIATION PLAN 0 CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) O EXCAVATE&DISPOSE(ED) a REMOVE FREE PRODUCT(FP) a ENHANCED BIO DEGRADATION(IT) <br /> J ISEE BA"FON BETA") <br /> Q Z <br /> oO Q CAP SITE(CD) O EXCAVATE&TREAT(ET) O PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> w� <br /> Q a O CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) O TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> a VACUUM EXTRACT(VE) O OTHER(OT) <br /> Z <br /> 0 <br /> 0 <br /> U <br /> HSC 05(BNS <br />