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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)J CONTAMINATION SITE REPORT <br /> EMERGENCYLV, HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCA AGENCY USE ONLY <br /> REPORT BEEN FILED 7 <br /> ❑ YES NO ❑ YES �NO 1 HEREBY CERTIFYTHAT I HANE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTK) SHOWN ON THE WSTRUCTION SHEET ON THE BACK PAGE OF:THIS FORK! <br /> REPORT DATE CASE i <br /> �p� <br /> (omi <br /> a <br /> j <br /> M `o M V __/ C 1 Y It -7 3 .SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE 7SIG <br /> - :�2 <br /> REPRES TING F-1OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR APIENCY NAME <br /> F <br /> ¢ LOCALAGENCY ❑ OTHER Ew <br /> ¢ ADDRESS 3 <br /> •a( /S1,RE 6 =' CITY C�STATE � ZIP <br /> w N E / 1J yJ•��AA 1`tt (c� i CONTACT PERSON <br /> i PHONEr <br /> U) + L `lJ1�liJT�1� ❑ UNKNOWN I�V`l•.,t L / 7L31 Ir`�Jl'� (wZ7� LLr?'GL-bI <br /> CL as ADDRE' IVOSS <br /> cr STREET CRY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> r m <br /> U <br /> ADDRESS �► <br /> o _ <br /> J 7 �^'- E-..�`� tom/ <br /> w STREET CITY COUNTY 21P <br /> I= CROSS STREET <br /> Z LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> cn <br /> ui z COGNPA PeDRAZA (2a ) _0333 <br /> w w REGIONAL BOARD PHONE <br /> CL <br /> cn NAME QUANTITY LOST;rUNSK)NOWN <br /> wQ� ia �:1� �� � <br /> =z (Z) <br /> U) ❑ UNKNOWN <br /> Z DATE HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> M y ❑ TANK TEST YANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> w M M o D y y UNKNOWN ❑REMOVE CONTENTS Ej?C/LOSE TANK&REMOVE ❑REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED Z ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o ❑ YES ❑ NO IF YES,DATE 4*MI' 0 y 1, Y ❑REPLACE TANK ❑ OTHER <br /> SOUR OF DISCHARGE <br /> CAUSE(S) <br /> w <br /> ¢� TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE SPILL <br /> (O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> U,ww CHECK ONE ONLY <br /> U ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z <br /> w j ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> U) ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY 0 POST CLEANUP MONITORING IN PROGRESS <br /> v dREMEDIATION PLAN ❑ CASE LOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> (SEE BACK FOR OETALS) EXCAVATE&DISPOSE(ED) E:] REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> J <br /> a zElCAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w O <br /> w�. <br /> Qa F--] CONTAINMENT BARRIER(CB) ❑� NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> p <br /> z <br /> w <br /> 0 <br /> O <br /> U <br /> HSC 05(A&90) <br />