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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCYSERVICES FOR LOCALE USE ONLY <br /> REPORT BEEN FILED <br /> ❑ YES � NO ❑ YES NO 1HEREBY CE T. HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> REPORT DATECASE A DISRRIBUT S N T STRU ION SHEETON THE BACK PAGE OFTHIS FORM <br /> 1 Dyi ( 5 9 2 0 z <br /> scx fl oar <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGMA <br /> r�frGN�.! Sceh)Ln7 zYC. <br /> (2,M ) 4;6 -3444 <br /> w REPRESENTING ❑ OWNEROPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME �7 <br /> R LOCAL AGENCY ❑ OTHER 'GAO T �(, Ait MA,.,�.� Sw.J LLis <br /> WA: ADDRESS <br /> r��`.^^"•�.""+tillii./VvV�CJJJ"""�+�� �aO«Yf!! ✓tea <br /> I ✓�_ 1 STREET Wk.{�(JV�-- Cm BATE •l�Wl <br /> w NAME ar <br /> ��..,�7 C'O1NTACT PERSON^ ^,,�,,.,.,,Y� PHONE <br /> { <br /> Z e �.0 I/a�s �. I.l��/� ❑ UNKNOWN W�'�f�'• \ -BcAu us , <br /> H y ADDRESS <br /> I X05 t.I. P�rZINaD SacctL�� +� 41UA <br /> STREET CITY STATE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> i ADDRESS <br /> y CROSS STREET <br /> i LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> 15.5. Co • Pl,r3uc 54vcJocrS +� �(�.I 5c 1�v�cm� (?.W )4fo$'3l'41 <br /> w w REGIONAL BOARD <br /> PHONE <br /> �� Lel�-u1 c.r3 ua��ru�- �vl�{� Iql )3�►-7�2� <br /> O (() NAME QUANTITY LOST(GALLONS) <br /> w <br /> <> u UNKNOWN <br /> N <br /> ❑ UNKNOWN <br /> Z DATE DISCOVERED c HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 3 y Z '7 u 7 y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> 6' DATE DISCHARGE BEGAN METHOD USED TO STOP DISTC�HARGE(CHECK ALL THAT APPLY) <br /> y>¢ y n UNKNOWN ❑REMOVE CONTENTS [X CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> 8 HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CIUNGE PROCEDURE <br /> o YES ❑ NO IF VES,DATE OMl q j Z ? d q y Z y ❑REPLACE TANK ❑OTHER <br /> SOORCE OF DISCHARGE CAUSE(S) <br /> TANK LEAK ❑ UNKNOWN CTTD-/� OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> %O ❑ PIPING LEAK ❑ OTHER T CORROSION ❑ UNKNOWN ❑ OTHER <br /> w CHECKONEONLY T <br /> ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> uZ ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMDTED ❑ POLLUTION CHARACTERIZATION <br /> jy ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> U <br /> REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE <br /> Iy:swwRanAw \`F <br /> O) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(17) <br /> ❑ CAP SITE(CD) EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY IRS) <br /> < ❑ CONTAINMENT BARRIER(CB) NO ACTION REWIRED INA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> m <br /> z <br /> W <br /> I <br /> MSC 051&'041 <br />