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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)L CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY sERvlc s FOR LOCAL;AGENCY USE ONLY REPORT BEEN FILED z HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE a YES NO Q YES NO DISTRI UTIQN 6H9WN T INSTRUCTION SHEET ON THE BACK PAGE DF.T IS FOR. REPORT DATE CASE 3 M M C y 3 DAE , . NAME OF INDIVIDUAL FILING REPORT PHONE ` SIGN RE m w REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME R w LOCALAGENCY ❑ OTHER a cc ADDRESS w G? - d STREET CRY STATE 21P J NAM CONTAOTPERSON PHONE g C/) fiA—1 UNKNQWN ) s cc a< r KESS m w ` s eA e .E STREET CRY STATE ZIP FACILITY NAME IF APPLICABLE) OPERATOR PHONE O �, �`".. U ADD SS a gggg 2w STREEf CRY COUNTY CROSS STREET a� LOCAL A CYAGE Y NAME CONTACT PERSON PHONE zm )�w W� I w it REGIONAL BOARD PHONE a." (�) NAME QUANTITY LOST(GALLNS) uJ o w UNKNOWN \\\ H J U) O (2) z D ❑ UNKNOWN z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS Lu M 3 -i L DI DII Y ❑ "TANK TEST ❑ TANK REMOVAL ❑ OTHER a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) m w Y UNKNOWN M M D Y ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE F-1REPAIRPIPING ® HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE YES ❑ NO IF YES,DATE M MI ® v Y ❑REPLACE TANK ❑OTHER SOURCE OF DISCHARGE CAUSE(S) ¢LU TANK LEAK UNKNOWN ❑ OVERFILL ❑ R TURE/FAiIURE ❑ SPILL h v PIPING LEAK F OTHER ❑ CORROSION t UNKNOWN ❑ OTHER rCL-al CSECONLYDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHEC NE ONLY Z NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED Q POLLUTION CHARACTERIZATION ❑ LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS U m ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) (WE eAcu saa WTAas( a Z E-1 CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) wO w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) s ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) a z w c4 HSC 05("0)