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�• `f�- tit L � <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ VES NO REPORT BEEN FILED 7 E::] YES <br /> ❑ NO I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INS7RU TION SHEET ON THE BACK PAGE OF THIS FORM <br /> REP/ORT DATE ' E• / � �� <br /> lM M D Y SIGN ' DATE / <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> Aln <br /> 2 S ( wl 6r-3 w <br /> w REPRESENTING ❑ OWNERIOPERATOR ❑ REGIO AL BOARD COMPANY OR AGENCY NAME <br /> S LOCAL AGENCY ❑ OTHER S L M �-p• I �1 1 V <br /> a ADDRESS IndD STREEoAC \l � <br /> I ZIP <br /> IM NAME , CONTACT PERSON [iYl / vf Pi PHONE <br /> UNKNOWN UNKNOWNiV.¢ J <br /> 0, <br /> ADDRESS �7'/���� .II <br /> a Q EOT� cm t STATE ZIP" <br /> FACILITYN (IFAPPLICABLE) OPERATOR PHONE <br /> a ADDRESS REt( • " •�, ��� 49S3// <br /> o <br /> w sr cm couxTr aP <br /> y CROSS STREET <br /> e4j LAP b rum <br /> O PHONE LOCALAGENCY _ AGENCY NAME CONTACT PERSON <br /> H <br /> �w <br /> w U <br /> w REGK)NAL OARD PHONE ' <br /> w (1) NAME QUANTITY LOST(GALLONS) <br /> 0 <br /> j ❑ UNKNOWN <br /> mO m <br /> � <br /> 2 <br /> w ❑ UNKNOWN <br /> I- DATE DISCOVERED I HOW DISCOVERED IN OR SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> M `� / o �Y �r ❑ TANKTEST TAN REMOVA THER <br /> DATE DISCHARGE BEGAN METHOD USED TO STO DISCHARGE(CHECK ALL THAT APPLY) •yU <br /> ❑ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING ) <br /> w M Y Y <br /> HAS DISCHARGE BEEN STOPPED 7 E]REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o ❑ YES ❑ NO IFVES,DATE M 4 o Yl r ❑REPLACE TANK ❑OTHER <br /> 1L SOURCE OF DISCHARGE CAUSE(S) G <br /> �Nj ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE,FAILURE ❑ SPILL _ ^ <br /> oyO --I PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER V1 <br /> ywn CHECK ONE ONLY <br /> O ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> w Z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> �y ❑ LEAK BEING 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 /> gr[ercarwoEr.Mq <br /> W9 ❑ 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) ❑ VENTSOIL(VS) <br /> ¢a <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) _ <br /> ()f�l� Girt et V 14WaS Ye Gp! wj <br /> Gve- GR�✓4G8 , 7wv (]GS7s /t-�O "`� -Zc�--�7 <br /> NSC OS IMYR <br />