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ji�A n�czss -� -In p <br /> UNDERGR ND STORAGE TANK UNAUTHOR D RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERrENCYSERVpts FO L+ALY USE ONLY <br /> ❑ VES Np REPORT BEEN FILED? El YES NO 1H REATIHAVFB15 Rj3 DT�yHI/SIN��/RMATI OACCORDINGTOTHE <br /> DI ON THE INSTR IOf7VS, v" r(PAGE OF TH 8 FOR�fl ATE 0CASES ^/{� C.�M M .SIGV DAT <br /> NAM IVIDUAL FILING jiEP�RJ PF�N_E� i <br /> m <br /> REP ES ING REGIONAL BOARD COMPA R ENCY NAM <br /> ❑ OWNERIOPERATOR ❑ f-� <br /> m LOCAL AGENCY ❑ OTHER <br /> Ls/ /V STAW P <br /> j NAM l f� r CONTACT PERSON PHONE ,, ry <br /> ¢ I`✓� ❑ UNKNOWN <br /> i ( W'�'f� <br /> n i ADDRESS <br /> m Cv►'L��- <br /> STpEET CT' STATE ZIP <br /> FACILITY NAME(IF VAP ABLE) OPERATOR PHONE N// <br /> I <br /> O <br /> li ADDRESSa <br /> w 4TREET cm couxrr r / <br /> t CROSS STR T <br /> m Rcd ► s <br /> O L ENCY AGENCY NAME CONTACT PERSON PHONE <br /> �m V �W w <br /> w R PHONE <br /> C16 <br /> m (i) NAME QUANTITY LOST(GAL <br /> a il <br /> UNKNOWN <br /> m ❑ UNKNOWN <br /> Z DATE DIrVERED A HOW DISCOVERED ❑ INVENTORY CONTROL ❑ UBSURFAC ONRORING NU�IIS�ANCECO IT <br /> 04 , u I o Lr Y ❑ TANK T ❑ TANK REMOVAL OTHER I I7 y� VST <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL TH APPLY) ` <br /> REMOVE <br /> REOVE <br /> REPAIR PIPING <br /> > HAS DIS ROE BEEN STOPPED Y r UNK ❑REPAIR TANKCONTENTS E TANK 6 FILM N PLACE ❑CHANGE PROCEDURE <br /> SO YES NO IF VES,DATE ❑REPLACE TANK OTHER In <br /> r Y 6 <br /> SOURCE DISCHARGE CAUSES) N <br /> ❑ ANK LEAK ❑ UNKNOWN ❑ OVERFILL VUNKI� <br /> URE/FAILURE ❑ SPILL <br /> O PIPING LEAK OTHER ❑ CORROSION OWN ❑ OTHER <br /> ww CHECKONEONLY <br /> ❑ UNDETERMINED SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> wp ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> m ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATK)N PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK IATE APPROPflACTION(S) <br /> F-1EXCAVATESDISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) E::] ENHANCED BIODEGRADATION(IT) <br /> APPROPRIATE <br /> zF F-1CAP SITE(CO) ❑ EXCAVATES TREAT(ET) ❑ PUMPS TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w <br /> w a ❑ <br /> CONTAINMENT BARRIER(CB) ❑ NO ACTK)N PEOUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL NS) <br /> m <br /> ❑ VACUUM EXTRACT NEI ❑ OTHER(OT) <br /> Ulvlfi� <br /> AtcGni <br /> M9C G3(A'B% <br />