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IN a qe)__uL1A_ <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br />❑ YES NO REPORT BEEN FILED 9 ❑ YES ❑ NO I HEREBY CERTIFYTHAT I. HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br />A IBUT SHOWN HE STR CTION SHEET E BACK PAGE OF THIS FORM. <br />REPORT DATE / � � �Y CASE# �' rF <br />NED DATE <br />N M OF INDIVIDUAL FILINGRE RT ,/ <br />PHONE <br />A <br />SI <br />rzlq <br />}Aawl <br />m <br />/Y <br />REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br />pLOCAL <br />AGENCY ❑ OTHER <br />wADDRESS <br />C� <br />52 2— <br />V STREET CRY STATE ZIP <br />wE <br />J <br />�fo <br />CONTACT PERSON <br />PHONE <br />F <br />❑UNKNOWN <br />Q <br />o CL <br />O_ < <br />U) <br />w� <br />A RESS <br />/� <br />tLtvl/ <br />�� / STREET C / STATE Ip <br />FACILITY NAM (IF APPLICABLE) <br />OPERATOR <br />PHONE <br />3 <br />o0mly <br />U <br />w <br />ADDRESS <br />STREET CRY- "1/{/ jZp <br />ZIP <br />y <br />CROSS STREET <br />it4cIt <br />o <br />r- <br />LOCAL AGEN Y AGENCY NAME <br />CO T CT PERSON <br />PHONE <br />w <br />w U <br />✓ 1r V <br />w w <br />a C <br />REGIONAL BOARD <br />/V / G <br />//�. q� <br />�V <br />P NE <br />/k �ZSs -313 - <br />d..? • <br />ti <br />(�) NAME QUANTITY LOST (GALLONS) <br />Lu <br />aJ <br />^� <br />UNKNOWN <br />m <br />(Z) <br />:� <br />U) <br />❑ UNKNOWN <br />z <br />z <br />w <br />DATE DISCOVERED <br />/ / <br />/Mj 7—.1 fyig <br />HOW DISCOVERED F-1INVENTORYCONTROL E:] SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />❑ TANK TEST TANK REMOVAL ❑ OTHER <br />! Mi 6 1 r <br />a <br />m <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />UNKNOWN <br />M D D Y Y l 9 <br />❑ REMOVE CONTENTS CLOSE TANK 8 REMOVE ❑REPAIR PIPING <br />w <br />p <br />❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED? <br />U <br />0 <br />YES [:]NO IF YES, DATE q <br />/-.I <br />❑REPLACE TANK ❑OTHER <br />/ Y Y <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />Q U) <br />❑ TANK LEAK UNKNOWN <br />❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br />y O <br />❑ PIPING LEAK ❑ OTHER <br />❑ CORROSION UNKNOWN ❑ OTHER <br />cn <br />w a <br />CHECK ONE ONLY <br />O <br />❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />w <br />F7 NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />cc I <br />cc I <br />LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />?< <br />O <br />REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />J <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />(SEE BACK FOR MALS) <br />< <br />00 <br />o <br />❑ CAP SITE (CD) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />uj <br />w < <br />❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />Q <br />❑ VACUUM EXTRACT (VE) ❑ OTHER (OT) <br />z <br />Lu <br />T-7 Y <br />