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0101' <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMNCY SERVICES <br />) FOR LOCA( - AGENCY USE ONLY <br />REPORT BEEN FILED? <br />VES NO YES NO <br />❑ ❑ <br />1 HEREBY CERnFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br />.DISTRIBUTION SHOWN ON THE INSTRUCTION SHEEP ON THE BACK PAGE OF THIS FORM <br />R/T/ )D�ATE 0 � � <br />• M Y <br />CASE 1 <br />SIGNED DATE <br />NAME OF INqIVQUpL FILING REPORT i <br />l.e �✓' <br />PHONE SIGNATURE <br />8- <br />i S <br />m <br />w <br />REPRES NTING ❑ pyyNEyppEgATOR ❑ REGIONAL BOARD <br />COMPANY OR AGENCY NAME <br />SLOCAL <br />AGENCY ❑ OTHER <br />ADDRESS 3o 5F' E. Ld-Z Y 3" loo►^ S oL�-1�>,�, ci4 9,5wol- <br />pry STATE IIP <br />j <br />NAME jj/� ^y <br />V a* DR, <br />I <br />TACT PERSON J� /y �/.,�{'L ,PHHONNE ry'� I��f <br />D/7 V A w/T �'T� 4, T <br />a <br />R n al 1 o ❑ UNKNOWN <br />, IpfV ) 1 ✓ <br />/T I <br />a <br />¢ <br />ADDRESS 10.7 �foc,AY�-t� <br />F, Di <br />STREET CITY STATE Zil <br />FACILITY NAME (IF APPLICABLE) <br />t.1PE� AOR Y� a i"1 PHONE <br />a <br />A° 1�F7 S, ��'c -o 3t-oGkd� �S�'�� <br />srREEr cm ccuxfY P <br />y <br />CROSS STREET <br />p <br />ww <br />LOCAL A NCV AGENCY NAME <br />P.o. QHS— tf <br />CONTACT PERSON <br />m, l <br />PHONE <br />ca��b8- <br />w <br />REGIONAL BOARD <br />�Lo ca <br />v <br />PHONE <br />NAME QUANTITY LOST (GALLONS) <br />X <br />UNKNOWN <br />N2 <br />UNKNOWN <br />Z <br />DATE DISCOVERED �yy <br />HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCECONDITIONS <br />u ✓ D Y O Y <br />❑ TANK TEST TANK REMOVAL ❑ OTHER <br />a <br />i <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br />UNKNOWN❑REMOVECONTENTSxCLOSE <br />M D Y <br />TANKB REMOVE ❑REPAIR PIPINGly <br />❑ REPAIR TANK ❑ CLOSE TANK a FILL IN PLACE ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED?Q <br />�Y <br />o <br />%�(j. <br />YES ❑ NO F YES, DATE -1 o D I V <br />Y ❑ REPLACE TANK E::]OTHER <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />¢ <br />,/ <br />TANK LEAK Mf UNKNOWN <br />❑ 3 <br />❑ OVERFILL E::] SUPTURE/FAILURE ❑ SPILL <br />w O <br />F-1PIPINGLEAK ❑� OTHER <br />CORROSION ' x UNKNOWN ❑ OTHER <br />T� <br />w wn <br />CHECK ONE ONLY <br />O <br />❑ UNDETERMINED SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHEECCK/ONE ONLY <br />w� <br />IJO NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMNTED ❑ POLLUTION C14ARACTERIZATON <br />i❑' <br />.y <br />O <br />LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDER WAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTIONS) EXCAVATE 8 DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BID DEGRADATION (IT) <br />ts£ APPROPRIATE <br />Rnonlual <br />W9 <br />❑ CAP SITE (CD) EXCAVATE a TREAT(ET) ❑ PUMPb TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />r <br />w < <br />❑ CONTAINMENT BARRIER (CB) NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />❑ VACUUM EXTRACT (VE) OTHER(OT) <br />^ �—❑ <br />0 <br />RSc m (� <br />