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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? I HEREBY CERTIFY THAT I HAVE DISTRIBUTED T IS INFORMATION ACCORDING TO THE <br /> YES NO ❑YES ❑ NO DISTRIBUTION SHOWN ON THE INSTRUCTION 4LET ON THE BAC AGE OF{{THIS FORM/ <br /> REPOR(T./DATE CASE. ( ,.,,, J�� �./ <br /> UM 1 ml SIGNED K lM/l/i L DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE / pp SIGNATURE <br /> ATL ✓ (?0) 60 - <br /> REPRESENTING ❑ OWNER/OPERATOR ❑ EGIONALBOARDcoMPANYORR AGENCY NAME 5 "� <br /> S pl�LOCALAGENCY ❑ OTHER5tm <br /> ADDRESS <br /> O 3 REE cm sT^�• ��-�P / <br /> j NAME CONTACT PERSON �F NE +/ <br /> ¢ O UN N st4 K (SIO I <br /> H a ADDRESS �d <br /> �/V���GR �(1 cm /{rr/�G srnTe`gra <br /> FACCII�[LIITTJY NAME(IF APAPLLICAB/L�E) s /�(Ry OPERATOR PHONE 0 <br /> lwLe4 <br /> ADDRESS 9S- b <br /> g <br /> 1 (016' arREer / L � cm couNry �7 P <br /> w <br /> m CROSS STREET <br /> 0 LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE / �/ <br /> zy 61 Z <br /> F= y , <br /> w- - <br /> w REGIONAL BOARD PHONE <br /> Gj ( ) <br /> y ()) NAME QUANTITY LOST(GALLONS) <br /> o Ia4S ❑ <br /> Z> UNKNOWN <br /> N ❑ UNKNOWN G` <br /> i DATE DISCOVERED �,j// HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS l- <br /> �M _q " D lv Y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> aDATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> ❑ UNKNOWN REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> W M D Yl YI <br /> HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o ❑ YES ❑ NO IF YES.DATE . D Y r ❑REPLACE TANK 'OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> go ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> a <br /> w Q ❑ PIPING LEAK ❑ OTHER ❑ DORROSK)N ❑ UNKNOWN ❑ OTHER <br /> ygw CHECKONE ONLY <br /> F >d UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w� ❑ NO ACTION TAKEN F-1PRELIMINARYSITE ASSESSMENTWORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> m y F-1LEAKBEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> Isff wxRnoEriuni <br /> 4 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ¢a ❑ CONTAINMENT BARRIER IDS) ❑ NO ACTION REQUIRED INA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENTSOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> q ^!h✓ U CrSTs Ve wl oJeo� a Al y 2-9 34Ae., 5ife <br /> A ssC�str ew� tv,LC. 6 e u.,n! dcferex erre_ -iea�pv, <br /> 8 no( ¢ X wF, ✓eg L- r"cz b y <br /> N9C ffi pwI <br />