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-ql� -a / � <br /> UNDERGROUND STORAGE ANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY.. <br /> ❑VES NO ❑ VES NO <br /> REPORT BEEN FILED? I HEREBY CER IFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TOTHE <br /> DI Tq PUTION nSHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE//OF THJISLF/ <br /> REPOR,TnDATE G CASES ( (/ ( 4 <br /> y SIGNED DAT <br /> NAME OF INDIVIDUAL FILING REPORT PHONE S ATURE <br /> L�h)21 t)J KwUL <br /> w REPRESENTING ❑ OWRERrOPERATOR ❑ REGK)NALSOARD COMPANYOR AGENCY NAME <br /> S LOCAL AGENCY ❑ OTHER 44, <br /> . s FFf� <br /> w ADDRESS <br /> P.O. [S ay, 3 8 g s NALY cm _ s Are�� ) <br /> w NAMCONTACTPERSON PHONE <br /> z L �(�' UNKNOWN 1 ) <br /> H u ADDRESS <br /> w 3� •� <br /> srATe <br /> FAC ITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS <br /> w CRY CWNlY 57 <br /> to CROSS STREET <br /> p LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> 2m <br /> wU <br /> w w REGX)NAL BOARD PHONE <br /> m (1) NAME QUANTITY LOST(GALLONS) <br /> EEr/w p <br /> a j UNKNOWN <br /> N <br /> ❑ UNKNOWN <br /> i DATE DISCOVEREDnv HOW DISCOVERED ❑ INVENTORY CONTROLE2r SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> / OMI Ll I DI✓ Y r ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> W M D D Y <br /> HAS DISCHARGE BEEN STOPPED? q ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o YES E::] NO !/y � <br /> NO IFYES,DATE /� �D Y Y ❑REPLACE TANK ❑ OTHER <br /> iD SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> ¢ ❑ TANK LEAK UNKNOWN ❑ OVERFILL RUPTURE/FAILURE ❑ SPILL <br /> a <br /> m0 ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w w C14ECKONEONLY <br /> m o- <br /> O ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHE�C[K ONEONLY <br /> i m JC I NO ACTION TAKEN F-1PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ¢ Y� <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 /> Pa=szRrw onus <br /> a ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> 00 <br /> w <br /> wa ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) El VENT BOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> N&c 05(&'00 <br />