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00 • <br /> UNDERGROUND STORAGE T NA K UNAUTHORIZED RELEASE (LEAK)/C6NTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVIC FOR LOCAL"AGENCY USE ONLY <br /> REPORT BEEN FILED?VES NO Q YES CAqp 1HEREBV CERTIFY THAT HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> REPORT DATE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OFTHIS FORM <br /> T CASE i <br /> S u O O T SIGN I /Ma -.{.L � — D EO <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> (,004 butvkcAA) (2&Y q&A033 1 kentaS <br /> REPRESENTING OWNEIVOPERATOR 0 REGIONALBOARD COMPANY OR AGENCY NAME <br /> S LOCALAGENCY Q OTHER Sam �C�P.{9-Ul✓1' �uK. <br /> A REBS /�7� <br /> STREET e Cm e- � STATE <br /> a(Ir-�[/ <br /> w NAME L CONTACT PERSON PHONE <br /> 55 CS1� UNKNOWN Dh [3� U <br /> (Ad7) <br /> yy ADDRESS ^ , '!�`,,,.y^,�,0a C <br /> ¢ �� srREEr N ✓� cdz> cm Sfv srATE C.� 75z <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> G alu+cwon <br /> < ADDRESS I <br /> � 3a S &Ti1EfT S • C� 1.J6�D cm 5 �� ca,emsJ �N^✓Z o <br /> CROSS STREET <br /> z LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> 6A VLrotia+ec,, }cat4l- 6o rt LkAK,-a k (aPl) `68033 p <br /> ww REGIONAL BOARD <br /> PHONE <br /> �)02.sS31l,S- � <br /> y (11 NAME QUANTITY LOST(GALLONS) <br /> e <br /> `; Tv �1 UNKNOWN <br /> 0� <br /> J� <br /> w O UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED 0 INVENTORY CONTROL 0 SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> u D Y TANK TEST TANK REMOVAL OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w <br /> MI o Y y f2� UNKNOWN REMOVE CONTENTS OSE TANK&REMOVE OREPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 Q REPAIR TANK E::]CLOSE TANK S FILL IN PUKE O CHANGE PROCEDURE <br /> o VES 0 NO IF YES,DATE u Oj OB y y REPLACE TANK OTHER <br /> SOURCE OF DISCHARGE tea- CAUSE(S) <br /> O TANK LEAK UNKNOWN E:] OVERFILL RUPTURE/FAILURE O SPILL <br /> < <br /> w O F-] PIPING LEAK OTHER 0 CORROSION UNKNOWN O OTHER <br /> ma CHECKONEONLY <br /> o� Q UNDETERMINED SOILONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> zZ F-1 NOACTIONTAKEN Q PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED Q POLLUTION CHARACTERIZATION <br /> m F__j LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> O O REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) a CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE B DISPOSE(ED) O REMOVE FREE PRODUCT(FP) O ENHANCED BIODEGRADATION Bn <br /> Is�ea rrnvErrssl <br /> w4 O CAP SITE(co) O EXCAVATE&TREAT(ET) O PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> ¢a CONTAINMENT 13ARRIER(CB) O NO ACTION REO�UI�fl�E�D a(NA) TREATMENT AT HOOKUP(HU) O VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) OTHER(OT) {/ Ly^,Zd Lf�Jq � -t <br /> z <br /> w <br /> E <br /> nsC 451 % <br />