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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCYHAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> O YES NO <br /> REPORT BEEN FILED? OYESO NO HEREBY CERTIFY THAT I AM REPORTED THIS NFORMATIONATO LOCAL OF OFFICIGNATED ALS PURSUANT URSUANT MENT LO SECTION 251807YEE AND THAT I HAVE <br /> RE/PORT <br /> jDATE l CASE, THEHLLLTH�NDS YCODF ,•'x <br /> l M VM [ y �y SIDNED f i i1 'j, ( � ,.E <br /> NAME OF INDIVIDUAL FLING RE POR (` PHONE SIGNATURE <br /> REPRESE F-1 LOCAL AGENCY O OTHER�PEFUTOR O REGIONAL SOl1R0 OMPANY _GENCY NAME <br /> p/+S r <br /> ADDRESS c <br /> F. <br /> BATE P <br /> j NAME CONTACT PERSON PHONE <br /> O <br /> m€ <br /> dui"� aj, /q. (AAW-4-531/ <br /> °1 UNKNOWN <br /> I ADDRESS <br /> S' cK 04 ��a6WOE <br /> y <br /> FACILITY NAME IF APPLICABLE) otl OPERATOR PHONE <br /> 4AnJ ) <br /> w <br /> ADDRESIT <br /> I `f l� �, <br /> CITYNY <br /> iA CROSS SIRE <br /> Gt� aeSf �n-�- <br /> 3 LOCALAGENCY - AGENCY NAME CONTACJ)yTPERSON <br /> O C PHONE <br /> w W �� J , l'r� <br /> w REGIONAL BOA <br /> vpE <br /> ( ) <br /> H (,) NAME QUANTITY LOST(GALLONS) <br /> """"owN <br /> O UNKNOWN <br /> I; DATE DISCOVERED /} HDWDISOOVERED O INVENTORY CONTROL O S RFACE MONITORING NU CONDITIO S <br /> M OM � 50 iV V D TANKTEST O TANKREMOVAL OTHER NUISANC <br /> DATE DISCHARGE BEGAN /' METHOD USED TO STOP DISCHARGE(CHECK ALL THAT Y) GZrj CG aL <br /> � E(y,/W/IWOWN O REMOVECONTENTS O REPLACETANK L CLOSETANK <br /> M M D D V <br /> HASDISCH BEENSTOPPED7 /7� ❑ REPAIRTANK REPAIRPIPNG CHANGEPRDDEDURE <br /> o YES O NO IFYES,DATE UM o o C r �r O OTHER <br /> � SOURCE OF DISCHARGE CAUSE(S) <br /> SO TANK LEAK - UNKNOWN ❑ OVERFILL O RUPTUREIFAILURE O SPILL <br /> 0 PIPINGLEAK ❑ OTHER ❑ CORROSION O UNKNOWN O OTHER <br /> ww CHECK ONE ONLY <br /> UNDETERMINED O SOIL ONLY O GROUNDWATER LDRINKING WATER- (CHECK ONLY IF WATER WELLS HAVEACTUALLY BEEN AFFECTED) <br /> CHECK .ELY <br /> ¢Z NOACTIONTAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED O POLLUTION CHARACTERIZATION <br /> UH O LEAK BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> O REMEDIATIONPLAN O CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE E <br /> later..rw " O ( D) O REMOVE FREE PRODUCT(RP) O ENHANCED Bq DEGRADATION(IT) <br /> wG O CAP SITE(CD) O EXCAVATE&TREAT(ET) O TNMP&TREAT GROUNDWATER(OT) 0 REPLACE SUPPLY IRS) <br /> O CONTAINMENT BARRIER(CB) n NOIACTION REQUIRED INA) O TREATMENTA�P(HlA Q VENTSOIL(VS) <br /> O VACUUM FMRACT Rel L�(d/OTHER(OT) C(SS PSrj <br />