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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)fCONTAMINATION SITE REPORT <br /> EMERGENCYHAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? <br /> YES YES 0 NO I HEREBY.-CE MIN.THAT f". '. D. GNRTEO GOVERNMENT`.EMPLOYEE AND THAT("HAVE. <br /> REPORTER 7N15".INFORMAT[ON TO L.i$P CIA1.S PURSUANT TQ,;SECTION 25)8 .7 OF <br /> REPORT DATE CASE s THE HEALTH CODE I: <br /> o r v SIGNED7 7 7DATE;: <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNAT E <br /> r' <br /> c <br /> o <br /> f RE�;MGENCY <br /> I�NAMEOWNEFVOPERATOR REGIONALBOARD COMPANY ENC <br /> p OTHER <br /> ¢ <br /> ��— <br /> ADDRESS <br /> o <br /> STREET CITY <br /> STATE <br /> N NAME CONTACT PE ON it PHONE zla <br /> z Q Ej UNKNOWN JR <br /> g� <br /> ADDRESS <br /> l <br /> LLI <br /> 2133 STREET / CRSTATE <br /> Y 3� � f/Nf <br /> FACILITY NAME(IF APPLICABLE) OPERATOR ;" PHONE <br /> z <br /> LD <br /> UaU ADDRESS <br /> O " <br /> 3/3 �Sf -- <br /> STREET <br /> COUNTY <br /> to CROSS STREET TYPE OF AREA av <br /> MMERCAL 0 INDUSTRIAL RURAL TYPEOFSUSINES5 [�] RETAIL FUEL STATION <br /> RESIDENTIAL OTHER FARM E ER <br /> p LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z Lu !# <br /> w <br /> Mu REGIONAL BOARD <br /> CL a jP PHONE <br /> r.0 (If NAME OUANTFTYLOST(GALLON,,) <br /> UI <br /> IU <br /> >> KNOWN <br /> `-U (2) <br /> N It UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> TANK TEST� TANK REMOVAL O OTHER o o v v " <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> t <br /> I} <br /> M M o o Y y NKNOWN � REMOVE CONTENTS O REPLACE TANK SE TANK <br /> p HAS OISCH E BEEN STOPPED? REPAIR TANK REPAIR PIPING CHANGE PROCEDURE <br /> p YES NO IF YES,DATE M M o o v rOTHER <br /> y SOURCE OF DISCHARGE TANKS ONLYICAPACITY MATERIAL j CAUSE(S) <br /> TANK LEAK UNKNOWN FIBERGLASS �', OVERFILL RUPTURElFAILURE <br /> 2 PIPING LEAK AGE a 3 YRS STEEL CORROSION UNKNOWN <br /> OTHER KNOWN 0 OTHER is SPILL F] OTHER <br /> Lu wa CHECK ONE ONLY <br /> UNDETERMINED SOIL ONLY GROUNDWATER = DRINKING WATER <br /> ,(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> Q a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) Ej CLEANUP IN PROGRESS= SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U H 0 NO ACTION TAKEN POST CLEANUP MONITORING IN PROGRESS NO FUNDS AVAILABLE TO PROCEEDEjokVALUATING CLEANUP ALTERNATIVES <br /> � <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> Z <br /> Lo <br /> CAP SITE(CD) EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED Bio DEGRADATION(IT) <br /> Lu <br /> CONTAINMENT BARRIER(CB) Q EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) E:] REPLACE SUPPLY(RS) <br /> Q TREATMENT AATHOOKUP <br /> /(HU) NOACTIONRREyOUIRED(NA) , ED---'O yTHER(OT)i <br /> ~ � <br /> w �� <br />