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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HASSTATE OF FICEOFEMER ENCYSERVICES FOR LOCAL'AGENCY USE ONLY <br /> ❑ VES NO REPORT BEEN FILED? <br /> VES ❑ NO 1 HEREBY CEFMFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> REPORT DATE DISTRIB TION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> CASE t c�/J/� r� <br /> M 3M 1 SMaNED ���� ; J/ l {�-L_ <br /> NAME OF INDIVI UAL FILING REPORT ATE <br /> PHONE SIGNATURE <br /> hams E hd�N (204 ) 96V-399,0 �/c c F✓� <br /> wREPRE5fNTING ❑ OWNERIOPERATOq ❑ gEGK)NAL BOAflD COMPANY OR AGENCY NAME <br /> S <br /> EVILODALAGENCY ❑ OTHER <br /> w <br /> ADDRESS <br /> p <br /> cm srATE /J� / <br /> m NAME CONTACT PERSON PHONE 21P <br /> Z, UNKNOWN rf— <br /> K <br /> y y ADDRESS <br /> c ,$DOU E. Fierr.7oA� S9— S,fdC�C-r-OJJ cm <br /> STPEEf C4 STATE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE1p <br /> a«+y GAS elo <br /> ADDRESS <br /> ?iso c FrK.ma..•f�— <br /> F sr l O/J cm �v C.I1� couNrr <br /> y CROSS STREET <br /> i LOCAL AGENCY AGENCY NAME OONTACTPERSON PHONE <br /> w <br /> J. <br /> w� REGIONAL BOARD PHONE <br /> na <br /> W (() NAME QUANTITY LOST(GALL NS) <br /> w /� <br /> UNKNOWN <br /> y Z V <br /> ❑ UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w n ❑ <br /> DATE DISCHARGE BEGAN Y f9, TANK TEST TANK METHOD USED TO STOP DIS CHAq (CHECK ALL THAT APPLY) 1� <br /> UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIfl PIPING W <br /> w M p Y <br /> p HAS DIRGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE E:]CHANGE PROCEDURE CJ <br /> o VES ❑ NO IF YES DATE al 2 j7CAUSE(S) <br /> � ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE <br /> w <br /> ¢j ❑ TANK LEAK UNKNOWN OVEflFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> ❑ PIPING LEAK ❑ OTHER CORROSION F�rLNKNOVIN ❑ OTHER <br /> H w CHECK ONE ONLY <br /> O VUNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER-(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w� ❑ NOACTWNTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> my 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 /> J IgEMGIt la1 RTAS <br /> 0 4 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> wa ❑ CONTAINMENT BARRIER(03) ❑ NO ACTION REQUIRED INA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> z To,*s Oe3 '/ r-4W0V Pe" .2/9/f?�7- _ /S Ooo ar9/Lr, �iPr� TBcIa� at <br /> •• 3' below �k /oma~ q �PSI� %4�k, tfbp SS [oti7�,nvGy�� 4r�t iN i..7, <br /> NSp&5(MW) <br />