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0 * C/ 'g, L)o 41 <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 YES NO <br /> t HEREBY CERTlFYTHAT i.HAVE DISTRIBUTED THI5INEORMATION ACCCiDiNG TOTHE <br /> YES NO ❑ <br /> DISTRIBUTION.SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF,THIS FORM <br /> REPORT DATE CASE 8 w <br /> ti+ <br /> M M v .Sr fctl DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> I' 1 ( ) <br /> w REPRESENTING O OWNERIOPERATOR 0 REGIONAL BOARD COMPANY OR AGENCY NAME _ <br /> LOCAL AGENCY Q OTHER <br /> iV ADDRESS o <br /> STREET CITY STATE ZIP <br /> w NAME CONTACT PERSON PHONE <br /> coJ <br /> Fn S EJUNKNOWN <br /> Q—Pit 1067) <br /> COL QADDRESS <br /> Q <br /> STREET CRY STATE 3IP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> 4 <br /> S t ) <br /> U ADDRESS <br /> �( <br /> we cRv couHTv zIP <br /> F, CROSS STREET <br /> �ry <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON n PHONE <br /> z w l 4 a <br /> w REGIONAL BOARD PHONE <br /> U) <br /> (t) NAME QUANTITY LOST(GALLONS) <br /> 0 <br /> oUNKNOWN <br /> m z (Z) <br /> co UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING 0 NUISANCE CONDITIONS <br /> Lu <br /> MI n� r v TANK TEST TANK REMOVAL OTHER <br /> ® DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> w M M o v v <br /> cc UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED? F-1 REPAIR TANK -1 CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> YES a NO IF YES,DATE mi MI Di d v v ❑REPLACE TANK a OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> co <br /> TANK LEAK UNKNOWN OVERFILL Q RUPTURE/FAILURE SPILL <br /> � <br /> o F_� PIPING LEAK 0 OTHER ® CORROSION UNKNOWN OTHER <br /> Lu w CHECK ONE ONLY <br /> O ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER E] DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w cr� NO ACTION TAKEN F__] PRELIMINARY SITE ASSESSMENT'WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> =N LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) a CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) F__] EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> J (SEE BACK FOR NAGS) <br /> a CAP SITE(CD) F__] EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> 0 0 o <br /> w� <br /> Lu a ❑ CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) OTHER(OT) <br /> -` <br /> w <br /> v <br /> HSC 05(SW <br />