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N . "me y5- va9 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCYONLY. <br /> ❑ <br /> VES NO <br /> REPORT BEEN FILED 7 [:] VES 1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE NO <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE eCAS �I�jES _ (� [Y xw ot/ a". 2- <br /> U u u� g Y SEED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> REPRESENTING COMPANY OR AGENCY NAME <br /> r ❑ OWNER/OPERATOR ❑ REGIONAL BOARD <br /> ¢ LOCAL AGENCY ❑ OTHER <br /> S <br /> ¢ ADDRESS <br /> 3TREI7 C" ST.TE ZIP i <br /> w NAME CONTACTPERSON PHONE <br /> i ❑ UNKNOWN <br /> ADDRESS <br /> N <br /> 6 <br /> $TREE! CT' STATE IP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> O <br /> a ADDRESS <br /> U <br /> O <br /> ti $TREE! CILY ,(, COU1T' ZIP <br /> -y CROSS STREET <br /> O LOCAL ENCU AGENCY NAME CONTACTPERSON PHONE <br /> Z y In� G <br /> ~w ( A D I <br /> Z U <br /> w w REGIONAL BOARDW PHONE <br /> �O <br /> w (1) NAME QUANTITY LOST(GALLONS <br /> 0 <br /> UNKNOWN <br /> N <br /> ❑ UNKNOWN <br /> i <br /> DATE <br /> II DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> O F u 0D2 DI Y v ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHAR ECK ALL THAT APPLY) <br /> a <br /> a UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> w M D D Y <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o O VES ❑ NO IF YES,DATE I ml a.1 <br /> %.I I d IT <br /> yj 4 <br /> Y ❑REPLACE TANK E::]OTHER <br /> SOURCE OF DISCHARGE AUS (S) <br /> ¢j ❑ TANK LEAK ZrIUNKNOWN ❑ OVERFILL �TURE/FAILURE ❑ SPILL <br /> hF-] E::]0 ❑ PIPINGLEAK OTHER CORROSION UNKNOWN ❑ OTHER <br /> ww CHECK ONE ONLY <br /> O ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w� ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> r ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY EDPOST CLEANUP MONITORING IN PROGRESS <br /> Oy ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE L DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) Q <br /> I�vcn Rn PeTunl <br /> a2 <br /> ca ❑ CAP SITE[CD) ❑ EXCAVATE B TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY IRS) <br /> w< ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> Si+G 14SSemQn� V%Ln b�a, N� �sAa, +r ci", a ;NE ►1Ah" a,doQfx4e(+ <br /> e� co�,o-AR„th�+;en.-Ttt� 5 wk� BE QLD Lop o11£ stcTbrr <br /> 0 <br /> Q <br /> Hsc rs Itis% <br />