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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />FOR LOCAL AGENCY USE ONLY <br />REPORT BEEN FILED 7 <br />❑ YES ❑ NO ❑ YES ❑ NO <br />E8 ERTIFYTHAT 1 HAVE DI TRIRUTED THIS INFORMATION ACCORDING TO THE <br />DISTRIBUT( SHOWN TRUCT N THE BACK PAGE OF THIS FORM <br />1 '' I <br />/ /-! /i.r(' �-. /C� <br />REPORT DATE <br />CASES <br />3V <br />(� / <br />SIG s DAT �. <br />M M <br />NAME OF INDI UAL FILING REPORT <br />PHONE` <br />SIGNATURE <br />e <br />m <br />T <br />( 10) o �6-1 <br />,Q <br />V O'er <br />Lu <br />REPRESENTKG OWNER/OPERATOR ❑ REGIONAL BOARD <br />COMP NY O AGENCY NA E % <br />CL <br />❑ LOCAL AGENCY 0 HER <br />cr <br />/��"� <br />ADDRESS O �r_ SC l' C�-- / 0� 2-(p6 <br />.00 <br />/ <br />STREET CITY STATE ZIP <br />J <br />co <br />NAME CONTACT=�N /7 _ <br />PHONE <br />4 <br />C <br />❑ UNKNOWN ( I l kto V7 ( <br />to) <br />Oa d <br />ADDRESS <br />f =D ��- qo,�2-038 <br />�© 38 ' <br />cl-w <br />C,s`�' <br />_STREET�3c <br />STATE Z P <br />FACILITY NAME (IF APPLICABLE) <br />3�i <br />OPE OR <br />"r ho �r�` <br />PHONE <br />Z <br />_ s <br />oAD <br />RESS <br />(/\•� /� 1y� <br />//^y///11 ,^ �� <br />////��/� ////^� <br />�✓ l ` r 1 " vl. <br />✓p� G/p" 1 <br />w <br />S Er CITY <br />CROSS STREET , <br />0 <br />Z- <br />z w <br />LOCALAGENCY AGE CYNAME CONTACT PERSON I�//� f <br />, l <br />/PHONE <br />Z <br />U <br />n <br />V V 3 o <br />(� <br />b20 _ 1 <br />I w <br />J <br />REGION ARD <br />PHONE <br />Q- Q <br />< <br />� ) <br />w O <br />(1) NAMElT p ff6 tlttll • QUANTITY LOST (GALLONS) <br />'i`o` :M1ax C: +� <br />,_ <br />J <br />.:_ ❑ UNKNOWN <br />c-utvLepa <br />f O <br />co <br />*. . <br />(2) <br />w- 1� liil <br />r .� ❑ UNKNOWN , <br />f <br />DATE DISCOVERED <br />HOW DISCOVEREDIDINyENTCRY WTIj SUBSURFACE NITORING ❑ NUI E CONDITIONS <br />D <br />TANK TEST TANK REMO�OTHERw ' �.. <br />El <br />aDATE <br />DISCHARGE BEGAN <br />METHOD US�'f� OP DISCHARGE (CHECK ALL THAT APPLY) <br />M D D y y ❑ UNKNOWN <br />❑ REMOV �OCNTENTS ❑ CLOSE TANK & REMOVE ❑ REPAIR PIPING <br />w <br />O <br />U <br />cn <br />E] REPAIR TANK CLOSE L IN P CE CHANGE PROCEDURE <br />HAS DISCHA EE STOP D ? <br />YES ❑NO IF YES, DATE I D <br />❑ REPLACE TANK HER <br />M D D V Y <br />If <br />L-� w�l <br />SOURCE OF DISCHARGE <br />AUSE(S) <br />aEl <br />LEAK ❑ UNKNOWN <br />❑ OVERFILL ❑ RUPTURE/FAILURE SPIL <br />U <br />F -]PIPING LEAK ❑ OTHER <br />E:]CORROSION ❑ UNKNOWN OTHER <br />uj ww <br />CHECK ONE ONLY <br />U <br />❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />w(nF-]NO <br />ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />Ir <br />c y <br />❑ LEAK BEING CONFIRMED ❑ PRELI N#AYSITE ASSESSMENT UNDERWAY F --]POST CLEANUP MONITORING IN PROGRESS <br />U <br />❑ REMEDIATION PLAN CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />J <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <br />(SEE HACK FOR DEFAI ) <br />az <br />uJ O <br />❑ CAP SITE (CD) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />wF- <br />CONTAINMENT <br />Qa <br />❑ BARRIER (CB) ❑ NO A REQUIRED ❑ TREATMEN HOOKUP (HU) ❑ VENT SOIL (V ) <br />❑ VACUUM EXTRACT(VE) OTHER(OT) <br />0/ <br />6 �,e C�E <br />0 <br />o�K t�� ►n 2 s . i9 � sor n was (�..�.e rho kt <br />Oki S e Ell ' ,o— w%- <br />L <br />1 <br />0 <br />D <br />;2q- <br />ON <br />2o- <br />ONI <br />cq-11111 <br />