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UNDERgROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SER ES FOR AGENCY USE ONLY' <br /> Q VES NO VES NO <br /> REPORT BEEN FILED 7 IH ESYCE FYTHATI HAVE DISTRIBUTED THIS I ORMATION ACCORDING TO THE <br /> � <br /> pI [BUT NON THE INSTRU <br /> REPORT DAIS (�' CASEa PAGE OF THIS FORM( <br /> VSIG — v <br /> Y DATE <br /> N FIND[VIDUAL FI REFpRT� PHONE SIG U <br /> REPRES TING <br /> Q OWNER/OPERATOR Q REGIONAL BOARD COMPANY OR AGENCY <br /> SLOCALAGENCY O OTHER <br /> ADDR 3 ' ! <br /> C WAh <br /> ZIPCO ACT ERSON <br /> z0 Pd V ' (/, 1��^7� O UNKNOWN 1 ��/� PHONE <br /> N • REEf CflV STATE SSD <br /> FACP TY NAME(IF APPLIC1A E) Op T (SPH NTE <br /> J ADI 3 ` l • ) <br /> w SIPEET ��n�. G�TI�r1 9S2��j <br /> w CROSS TREET Y �� �� coVxTv 1P <br /> /�!Y I W� <br /> U w LOCAL EryGV� J AGENCY NAME CONTACT PERSON PHONE <br /> w w REG p g�170( fl❑❑❑ I <br /> PHONE <br /> w (�) NAME QUANTITY LOST(GALLO ) <br /> Uy� <br /> < [Er UNKNOWN <br /> 45 � <br /> m <br /> Q UNKNOWN <br /> Z DATED VERED HOW DISCOVERED VENTORY CONTROL 0 UBSURFACE MONITORING Q NUISANCE CONDITIONS <br /> w T1 <br /> �J 0 TANK TEST TANK REMOVAL OTHER <br /> M D Y Y <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHA E(CHECK ALL THAT APPLY) <br /> wD Y Y UNKNOWN REMOVE CONTENTS CLOSE TANK&REMOVE OREPAIR PIPING <br /> HAS DI ARGE BEEN STOPPED 7 REPAIR TANK Q CLOSE TANK E FILL IN PUCE 0 CHANGE PROCEDURE <br /> o YES NO IF VES,DATE qd Otl Y REPLACE TANK O OTHER <br /> SOURCE OF DISCHARGE �✓✓�[[M��I CAUSE(d) <br /> ¢j TANK LEAK UNKNOWN E] OVERFILL 0 RUPTURE/FAILURE O SPILL <br /> a <br /> wUPIPING LEAK O OTHER Q CORROSION UNKNOWN O OTHER <br /> w w CHEC NE ONLY <br /> UNDETERMINED ❑ SOIL ONLY GROUNDWATER DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w O NO ACTION TAKEN O PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMRTED O POLLUTION CHARACTERIZATION <br /> jy O LEAK BEING CONFIRMED 0 PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> U O REMEDIATION PLAN F__j CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) a CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE a DISPOSE(ED) REMOVE FREE PRODUCT(FP) O ENHANCED BIODEGRADATION(IT) <br /> Z rcEE awx Rll OFfwV/ <br /> p O CAP SITE(CO) EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT)O REPLACE SUPPLY(RS) <br /> is CONTAINMENT BARRIER(CB) NO ACTION flE0U1gE0(NA) O TREATMENT AT HOOKUP(HU) E:j VENTSOIL(VS) <br /> VACUUM EXTRACT(VE) Q OTHER(OT) <br /> a <br /> HSC M lasol <br />