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El <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />REPORT BEEN FILED 7 <br />a YES NO YES ❑ NO <br />FOR IOCAL'AGENCY USE.:ONLY <br />i HEREBY CEFMFYtHAT ( HAVE DISTRIBUTED THIS INFORMA7KNt ACCORDING TO THE <br />DISTRIBUTION SHOWN ON THF_INSTAUCTION SHEET ON THE BACK PAGE OFTHISFORWX. <br />' <br />REPORT DATE <br />CASES <br />(/ <br />-i Ami `B Y <br />SKaMED DATE <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE SIA RE <br />wREPRESENTING <br />c <br />� WNER/OPERATOR ❑ REGIONAL BOARD <br />OCAL AGENCY ❑ OTHER <br />C®MPANY OR AGENCY NAME <br />3 � � 5 � �� fhf)j�) <br />�✓� MA <br />¢ <br />ADDRESS _ } <br />.�OL'J, <br />9 CITY <br />w <br />in <br />NAME <br />�C <br />CON <br />PHONE <br />-51 <br />U <br />l <br />!i Gi (fv UNKNOWN <br />d <br />0 - <br />CL ¢ <br />ADDRESS <br />y�Bjf <br />STREET CITY STATE zip <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />PHONE1(2,0%,j <br />ADDRESS j (� 01 5 A 6 <br />- o <br />R Ei� j Y�l_.� u <br />ZIPw <br />CROSS STREETff9 <br />j i� /� p <br />� � ! J `I Qi VLE <br />O <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />ze <br />8 <br />\PHONE / q <br />w w <br />REGIONAL BOARD <br />C/Ir� <br />�I <br />c <br />li <br />:r <br />m <br />(1) NAME QUANTITY LOST (GALLONS) <br />o <br />�`'� gg �(^ <br />NKNOWN <br />(�i t 6 lE) <br />m z <br />(�) <br />❑ UNKNOWN <br />i <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ INVENTORY CONTRA ❑ SUBSURFACE MONITORING NUISANCE CONDITIONS <br />ui <br />2 <br />M) o v r <br />❑ TANK TEST ❑ TANK REMOVAL OTHER �' S °ii j S . t. <br />< <br />m <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />cc <br />UNKNOWN <br />M D Y Y <br />❑ REMOVE CONTENTS ❑ CLOSE TANK & REMOVE ❑ REPAIR PIPING <br />❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE [:]CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED Z <br />o <br />❑ YES ❑ NO IF YES, DATE <br />E] REPLACE REPLACE TANK OTHER I i '' <br />MAcA <br />MI D v v <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />¢ U <br />❑ TANK LEAK UNKNOWN <br />❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br />a <br />m O <br />PIPING LEAK ❑ OTHER <br />❑ CORROSION UNKNOWN ❑ OTHER <br />N a <br />CHECK ONE ONLY <br />vNDETERMINED <br />❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />z <br />NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />jN <br />❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />U <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <br />(SEE SCK FOR DEFAtM <br />Z <br />o O <br />❑ CAP SITE (CD) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />Qa <br />❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />❑ VACUUM EXTRACT (VE) OTHER (OT) <, <br />-. j <br />