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-- <br /> OUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> MCA NO REPORT BEEN FILED? [:3 YES Q NO )HEREBY CERT)FYTHAT I.HAVE.DISTRIBUTEt)THIS INFORMATION ACCORDING TO THE <br /> DIS UTION S OWN ON T W STRUCTION EET ON THE BACK PAGE O THIS F M <br /> pi <br /> E +7 CASE# k 0 II � { <br /> M f 4- 0Y SIGHED.. ....[. DATE <br /> NA <br /> E OF INDIVIDUAL FILI G REPORT PHONE SIGNATURE <br /> o <br /> ca REPRESENTING �} REGIONAL BOARD COMPANY OR AGENCY NAME <br /> w� 6WNER/OPERATOR {� <br /> R LOCAL AGENCY Q OTHER _ <br /> ADDRESS <br /> 137 //y�/[��[� f /� <br /> STREET • C1T1' STAT ZIP <br /> w NAME CONTACT PERSON PHONE <br /> co <br /> � y i <br /> " Q UNKNOWN Mr (q& u V <br /> in <br /> a a ADDRESSLu <br /> iy ///�� /}'� gw �� /�_, A //� (/n�j <br /> QD_ ; 2-623! / STR�- L>�•�"N—+ CRy W �'— b'� IAT64 ,7(fJ/ <br /> FACILITY NAME(IF APPLICABLE) OPERATOR UPHONE <br /> o p ( ) <br /> ° ADDRES <br /> U STREET - <br /> oHr <br /> d E <br /> Lu <br /> CITY COUNTY f ' •�>�ZIP <br /> CROSS STREET <br /> Lo <br /> LOCAL AIJENCY AGENCY NAME CONTACTPERSON PHONE <br /> ul <br /> ! <br /> Lu <br /> w REGIQh! ARD PHONE <br /> CL <br /> y (�) f V QUANTITY LOST(GALLONS) <br /> z f clIZI— UNKNOWN <br /> a J W b \! <br /> En Z (2) <br /> UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING � NUISANCECO DITIONS <br /> �N ( M a Y ❑ TANK TEST Q TANK REMOVAL OTHE c <br /> a ATE DISCHARGE BEGAN METHOD USED TO STOP DIRGE(CHECK ALL THAT APPLY) <br /> m <br /> UNKNOWN REMOVE CONTENTS CLOSE TANK&REMOVE 0 REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED? E]REPAIR TANK �CLOSE TANK&FILL IN PLACE O CHANGE PROCEDURE <br /> o YES E:] NO IF YES,DATE (M MI rp 7 Y 0 REPLACE TANK OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> ¢� � TANK LEAK UNKNOWN ❑ OVERFILL � RUPTURElFA1LURE E] SPILL <br /> vai PIPING LEAK F OTHER CORROSION UNKNOWN OTHER <br /> w w CHECK ONE ONLY <br /> rn a <br /> O ❑ UNDETERMINED SOIL ONLY GROUNDWATER � DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY 13FEN AFFECTED) <br /> CHECK ONE ONLY <br /> z 0 NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> � LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> U REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) O ENHANCED BIO DEGRADATION(ITy <br /> f�s�cK ran oFtw� <br /> Q z <br /> 00 ❑ CAP SITE(CD) 0 EXCAVATE a TREAT(ET) PUMP 6 TREAT GROUNDWATER(GT)0 REPLACE SUPPLY(RS) <br /> w¢ ❑ CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> a <br /> VACUUM EXTRACT(VE) F-1 OTHER(OT) <br /> Ll ST '�a• a«�;P t rSCt c�.c ' Sos.d tl�T Alt <br /> HSC OS("o) <br />