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-. ..I <br /> 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 7 <br /> YES �NO ❑ YES �O 1 HEREBY CER7IFYTHAT 1 HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OFTHIS FORM. <br /> REPORT DATE CASES <br /> Q <br /> U <br /> NAM OF INDIVIDUAL FILING REPORT PHONE SIG R <br /> U rhJ vQ ► Csv (96 ) L(�o '33'(C? <br /> w REPRESENTING ❑ OWNER/OPERATOR E] REGIONAL BOARD COMPANY OR AGENCY NAME <br /> R ❑ LOCAL AGENCY ^OTHER �l ./I� <br /> Lu <br /> cr <br /> ADDRESS <br /> `5TREET CITY H I,H STATE ZIP <br /> J NAME i CONTACTPERSON /PHONE <br /> zco <br /> ¢ } R W I ❑ UNKNOWN (xr, <br /> co <br /> a a ADDRESS'LLI <br /> )[j/ <br /> 1)- /V( I&di./ STREET CRY �S �C / STATE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS <br /> fluW �F If L STREET CTI -�.� �`'� � COUNTY '� ZIP <br /> y CROSS STREET C <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z <br /> W z ,S' _)c4 ��,�J L�h 1 c (�, -u✓�cc �� t t :'� r�, 5 (- �z )`fb '•_3 4 b�' <br /> w w REG NAL BOARD PHONE <br /> a <br /> rk )Z55 - 3erc <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> O <br /> w � <br /> <> �/ - C UNKNOWN <br /> m 5 (Z) <br /> �z <br /> w <br /> ❑ UNKNOWN <br /> f DATE DISCOVERED HOW DISCOVERED 0 INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> J MI �MI D1 `� DI L v v ❑ TANK TEST ❑ TANK REMOVAL OTHER �.• �(�}�✓L .� Il• - D,5 �dJ r� <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> W M D D Y y UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> C, HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLO.5E TANK&FILL IN PLACE 4 CHANGE ROCEDURE <br /> U) <br /> E52YES ❑NO IF YES,DATE v'M MI GI .1 <br /> '.1 y y ❑REPLACE TANK OTHER tt/YL�Z�L` C.7 <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> 05)O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION k UNKNOWN ❑ OTHER <br /> u,aw CHECK ONE ONLY <br /> O ❑ UNDETERMINED ❑ SOIL ONLY Da�GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> D F-1LEAK BEING CONFIRMED F—] PRELIMINARY SITE ASSESSMENT UNDERWAY 0 POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ 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 /> J (SEE MACK FM DETn ) <br /> a z ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP 6 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w O <br /> w a ❑ CONTAINMENT BARRIER(CB) E ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> ❑cr <br /> VACUUM EXTRACT(VE) OTHER(OT) <br /> co <br /> z <br /> z <br /> w <br /> O <br /> U <br /> HSC 05(?N_0) <br />