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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LE AK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGE SERVICES FOR LOCALAGEN USE OIyI,Y <br /> ❑ YES P1O REPORT BEEN FLED? YES ❑ NO 1 HEREi3Y;CERTIFI`THAT I AM;A PESIP. MTED GOVERNMENT:EMPLOYEE AND 7H11T 1 HAVE <br /> :AEPSIFiTEO TNiS iIVFORMATION TO l OCAL OFFICIALS RURSUANT TO SECTION 251801`OF <br /> REPORTDATE CASE• THEH AN YCODE <br /> OM 7 .1 <br /> �D ' y �Y E D <br /> . a <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> m4e 4]' <br /> Q REPRESE ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAM <br /> wLOCAL AGENCY ❑ OTHER 14 h 1 (iJJ�d F n,, <br /> ADDR S V �-�rvu� Q /J <br /> Iti o) STREET .S� Y <br /> STATE Z"2 <br /> NAME C NTACTPERSON !I PHONE /� <br /> �� ' ❑ UNKNOWN 1 f P/yu bj')SY«�-3G 7 7 <br /> a AD RESS DO S C,Y4V�T�, IC// <br /> STREET <br /> GffY STATE ZIP <br /> FAC ITYNAME(IFAPPLICABLE) OPERATOR PHONE <br /> Q ADDRESS <br /> I. <br /> 5 tIPEI r <br /> y CROSS STREET TYPEOFAREA gCOMMEACIAL ❑INDUSTRIAL❑RURAL TYPEOFBUSINESS n RETAIL FUEL STATION <br /> waS E::]RESIDENTIAL 0 OTHER I F ❑ FARM 0 OTHER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON ); . ' PHONE <br /> w --- , <br /> REGIONAL BOARD <br /> PHONE <br /> a. ` <br /> I KJ 1 I 1 <br /> y (�) NAME 1` QUANTITY LOST{GALLONS) <br /> I{ ( ❑ UNKNOWN <br /> (2) <br /> x ❑ UNKNOWN <br /> i OATEDI ED How DI VERED <br /> INVENTOR CONTROL .x URFACE MONITORING ElNUISANCE CONDITIONS 1 <br /> �r �v D TANK TEST TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD US-W TO STOP DISCHARGE(CHECK ALL THAT AP <br /> t- Ii <br /> D Y Y <br /> UNKNOWN REMOVE CONTENTS j❑ REPLACE TANK CLOSETANK <br /> w M AI D �! <br /> HAS DI HARGE BEEN STOPPED? <br /> /'q) 2 F <br /> EDREPAIRTANK'S ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> YES [:] NO IFYES.DATEM (0. AD �D O r ❑ OTHER I <br /> w SOUZ;Z�ANJ <br /> ISCHARGE TANKS ONLYICAPACITY MATERIAL ! CAUSE(S) <br /> LEAK ❑ UNKNOWN GAL. ❑ FIBERGLASS ? OVERFILL ❑ RUPTURFrFAILURE <br /> I <br /> PIPING LEAK AGE YRS STEF1 I RROSION ❑ UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER I{ $ ❑ SPILL ❑ OTHER <br /> Lu CHECK ONE ONLY I <br /> i <br /> U ❑ UNDETERMINED E 0SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATERT (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> 2 y <br /> Lout e 0 SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESSE], SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) O <br /> I U y Q NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAq�TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> f CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) it <br /> �� <br /> z F-1CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> tu <br /> O O I aM <br /> F-] CONTAINMENT BARRIER(CB) ❑ EXCAVATE 6 TREAT(ET) E] PUMP&TREAT GROUNDWATER(GT) REPLAr ESUPPLY(RS)Irde i <br /> f qiI ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) E;/OTHER(OT) ip <br /> ytL ' s <br /> lyk <br /> „ 05("7) <br /> J • <br />