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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> AS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY <br /> EMERGENCY HUSE QI�L Y <br /> REPORT BEEN FILED 7 ❑ YES ❑ NO iHEREBYCERTIFYWTI;HAVE DISTRIBUTEDTHISpffORIAAT1ON ACCORDING TOTHE <br /> ❑ YES NO DISTRIBUTION SHOWN ON THE/NSTRUC170N SHES ON THE BACK PAGE OFTHIS FORNL. <br /> REPORT DATE /ice 1 CASE s <br /> O 7 l rl SGNED - - - BATE <br /> NAME OF INDIVIDUAL FIL1N�GrREPORf <br /> PHONE SIGNATURE ^ <br /> REPRESENTING ❑ OVYNEfVOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME �m Q U 1 V% (-bl"A h l <br /> PIxb It c- ��-N^Se c-v t tees �i ror%rr) <br /> p 'LOCALAGENCY ❑ OTHER <br /> a q <br /> ADDRESS 3r� 1��r sto c� C <br /> Crt'r STATE ZIP <br /> BEET PHONE <br /> w NA E M C.ON'ACT1"R UNC t A p �[ '] <br /> m (�y 1 •"L r� ❑ UNKNOWN ►�'`�'� `""7 ' ` �Q t ) i�0� O 0 <br /> N <br /> z <br /> a ADDRESS �'1 I t�T r <br /> D 13 0 `� d-1P .��` � STAT P <br /> � STREET <br /> FACILITY NAME(iF APPLICABLE) OPERATOR PHONE <br /> Lo <br /> U ADDRESS b g- �/C CS — <br /> �-�a c � SQ.h�aa�u ►� 9 <br /> OJ STREET CITY C;OVNTY P <br /> CROSS STREET t� <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> zY, .�aactr Ca aytn P L" yllta� �r <br /> w U PHONE <br /> L2 w REGIONAL BO RD ` <br /> Com„��"(`OC v l I ) <br /> m (�) NAME QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> m O <br /> N I UNKNOWN <br /> DATE <br /> II DISCOrVERREEDI HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> ` W ' MI �1 0 �Y ❑ <br /> TANK TEST TANK REMOVAL ❑ OTHER <br /> w <br /> ~ <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> am <br /> r� UNKNOWN ❑REMOVE CONTENTS CLOSE TANKS REMOVE ❑REPAIR PIPING <br /> 0" HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> `n YES ❑ NO IF YES.DATE vI ❑REPLACE TANK ❑OTHER <br /> a �p r <br /> ul <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> a ❑—TANK LEAK +UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> 140 ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w m CHECK ONE ONLY <br /> co a. <br /> U a. ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER C] DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ❑ NO ACTION TAKEN n PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED <br /> Lu <br /> ❑ POLLUTION CHARACTERIZATION <br /> y ❑ LEAK BEING CONFIRMED /�L]{ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PIAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE d DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BID DEGRADATION(IT) <br /> J (5eE SACK fan OETAA5) <br /> a Z ❑ CAP SITE(CD) EXCAVATE d TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Lu <br /> 0 ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> uw a <br /> cl- <br /> ❑ VACUUM EXTRACT(VE) ❑ <br /> OTHER(OT) <br /> =( e r rest L eW o -� IAS f e y%b J a-l a p U ems- <br /> wr �r-E-, s t-�->� p lace-1 L r, L-04:) grid <br /> U <br /> TISC 05 Mw <br />