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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY <br /> REPORT BEEN FILED 7 ❑ YES ❑ NO <br /> YES No 1HERESY CERfIFY7HAT.l HAVE DISTRIBUTED THIS INFORMATION ACCORDING TOME <br /> DISTRIBUTIQN SHOWN ON THE NSTRUCTKr SHEET ON THE BACK FACE OF THIS FORM <br /> REPORT DATE CASE• - <br /> 2- -93 <br /> I�N �u qv SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> hu <br /> R. S avP,� I y6Y tom, <br /> w REPRESENTING ❑ OWNENOPERATOR ❑ REGIO ALBOARD COMPANY OR AGE CY NAME _ 3 <br /> S LOCAL AGENCY ❑ OTHER LkW4�' ► <br /> ¢ ADDRESS <br /> ✓7 <br /> ,, <br /> srAl <br /> J NAME �^ ]�I d CONTACT PERSON �1 PHONE <br /> i M AT% 1 (A� UNKNOWN M GL, aD�1 e(e$ <br /> a g ADDRESS ^ 1'/ <br /> ¢ — • I STREe lT v �F--Ip%le- cm .ST(7G7�7�� srATe �T <br /> FACILITY NAME(IF APPLICABLE) P IhLTY <br /> _ OPERATOR PHONE <br /> M wl ) f3 $ <br /> ADDRESS 'y/ 5_0 <br /> / ,�,/ <br /> w <br /> 5/O 0 {�SlL ' ( 1 h- / I cm �calNrr/ ('JzIv <br /> w CROSS STREET <br /> N Arlt <br /> O LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> 2y <br /> z W <br /> Z <br /> U <br /> w 1 P14S <br /> w <br /> REGIONALBOARD PROW <br /> w (1) NAME QUANTITY LOST(GALLONS) <br /> 0 <br /> <J � �' Q ❑ UNKNOWN \(� <br /> i (2) 17 <br /> Z <br /> ❑ UNKNOWN ( <br /> z DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MON TORING NUISANCE CONDnITIONS <br /> O� o v 3r ❑ TANK TEST ❑ TANK REMOVAL OTHER �GS <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHEdk ALL THATAPPLY) <br /> ¢ M D y r E] UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING v <br /> p HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> 0 ❑ YES ❑ NO IF YES,DATE M u o r r ❑REPLACE TANK OTHER <br /> 0 SOURCE OF DISCHARGE CAUSES) <br /> ❑ TANK LEAK IWUNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> 00 ❑ PIPINGLEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> ww CHECKONEONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHE ONE ONLY <br /> Z Z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> �r ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> OW ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PROOUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> Pff va Rn oeT.usl <br /> a Z ❑ <br /> 59 CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ~ ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED INA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> wQ <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> _'% +1,1.w��es T—p-i Lz- 1 <br /> f e5f, r/•�Tit s iressessr�- <br /> d e v,.wd � r� o � Ar <br />