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0 GT6 - v �a <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY <br />HAS STATE OFFICE OF EMERGENCY SERVICES <br />FOR LOCAL AGENCY USE ONLY <br />❑ <br />REPORT BEEN FILED 7 <br />YES NO YES �O <br />❑ <br />1 HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br />DISTRIBUTION SHOWNON THE INSTRUCTION SHEET ON THE BACK PAGE OFF THIS FORM <br />REPORT DATE <br />CASECQ/24�AT <br />M <br />MI Y <br />� <br />SIGNED <br />NAME OF INDIVIDUAL FILINNG� REPORT <br />SIGNATURE <br />/rte <br />(PHONE is Z2— <br />[�iko!�' <br />Zs' 2— <br />dasn' <br />REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD <br />COMPANY OR AGENCY NAME <br />pE:p <br />LOCAL AGENCY ❑ OTHER <br />¢ <br />ADDRESS <br />STREET <br />CITY STATE OSk ZIP45201 <br />wJ <br />NAM <br />PHONE <br />n > <br />� <br />❑CONTACTPERSON <br />(,Rol <br />)9 yft UNKNOWN <br />a Q <br />Na <br />ADDRESS <br />Lu <br />¢ <br />TREET <br />CITY STATE 21P <br />FACILITY NAME (IF APPLIC BLE) <br />OP TOR <br />PHONE <br />z <br />5 <br />(a 82-,qg1(, <br />¢ <br />ADDRESS <br />U <br />O <br />w-1 <br />q <br />ftI v. STREET <br />r <br />CITY COUNTY ;ZIP9J <br />CROSS STREET <br />U <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />zc) <br />UJ <br />w U <br />w Lu <br />REGIONAL BOARD <br />PHONE <br />Q <br />co <br />(7) <br />NAME QUANTITY LOST (GALLONS) <br />z �w <br />[e -UNKNOWN <br />QJ <br />F- <br />m > <br />�� <br />(2) <br />UNKNOWN <br />Z <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />Lu <br />�M D� D y, r <br />❑ TANK TEST X TANK REMOVAL ❑ OTHER <br />a <br />m <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />M M D D Y Y l <br />UNKNOWN <br />x <br />❑ REMOVE CONTENTS CLOSE TANK & REMOVE ❑ REPAIR PIPING <br />p <br />❑ REPAIR TANK CLOSE TANK &FILL IN PLACE CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED 7 <br />o <br />® YES ❑ NO IF YES, DATE <br />E] REPLACE TANK ❑ OTHER <br />I a D o r <br />y <br />w <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />¢ <br />❑ TANK LEAK UNKNOWN <br />❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br />0 Q <br />U <br />❑ PIPING LEAK ❑ OTHER <br />❑ CORROSION ® UNKNOWN ❑ OTHER <br />w w <br />CHECK ONE ONLY <br />na <br />U <br />❑ UNDETERMINED ❑ SOIL ONLY <br />❑ GROUNDWATER ❑ DRINKING WATER • (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFEC ED) <br />CHECK ONE ONLY <br />❑ NO ACTION TAKEN ❑ <br />PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />w cn <br />cc N <br />❑ LEAK BEING CONFIRMED ❑ <br />PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br />U <br />❑ REMEDIATION PLAN ❑ <br />CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTION(S) <br />❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />J <br />o z <br />(SEE BACK FOR DETAIS) <br />❑ CAP SITE (CD) <br />❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />� U <br />❑ CONTAINMENT BARRIER (CB) <br />E] NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />wQ <br />¢ <br />❑ VACUUM EXTRACT (VE) <br />❑ OTHER (OT) <br />cnC.tissE�►+►.�-�saruj <br />w <br />� '(� � 1C-�FLl�l� D 1 � G OtiJ -i-a M i N o��- v4 <br />0 <br />0 <br />U <br />