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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 )HEREBY CERTIFY THAT I.HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑YES NO YES NO DISTUE TI SHOWNONT TRUCTION SHEET ON THE BACK PAGE OF <br /> REPORT DATE CASES / <br /> (1.11M I 4 D <br /> NAME OF INDIVIDUAL FILING RT PHONE SIGNATU <br /> //6�-3Y <br /> w REPRE ENTING ❑ OWNERAWERATOR ❑ REGIONALBOARD PANYOR AGENCY NAMll <br /> N <br /> SLOCALAGENCY ❑ OTHER 0mr <br /> ADDRESS <br /> vP� <br /> STREET cm <br /> w NAME CONT T)P�ERSON (PHONE O 7 <br /> (1�) `LvJ�l/�d�I �a rS^IV7vS/I•Q1�J�//U�_ <br /> ✓AG! /L UNKNOWN <br /> ADDRESS S O/L 4r�Yj/ Of •+ (.T�/�q'rS!Sh dVnL��S- <br /> At✓T�ENvN''�l9r <br /> 9(�/U FA5.AT NAME(IF APPLICABLE) OPERATOR PHONE <br /> A 4- U444� y <br /> ADDRESS #U Aom ✓�- 5 ,, m <br /> STREET <br /> CROSS <br /> LOGNAGENCY ENCU NAME NT CT <br /> d ON PHONE <br /> L, 6,A <br /> PHONEw REAL NAME QUANTITY LOST(GALLONS) <br /> G;J�K <br /> �N <br /> T"a <br /> OS"WO <br /> -Na O) / <br /> > mih - <br /> �v1/Y�11 <br /> H ❑ UNKNOWN <br /> i DATE DISCOVERED 7((� NOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING <br /> J ❑ NUISANCE CONDITIONS <br /> u �N1 O V o �v ❑ TANKTEST ❑ TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHODUSEDTO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> w u D r <br /> UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> 1 vI <br /> HAS DISCHARGE BEEN STOPPED T ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> S2 �S ❑ NO IFYES,DATE O✓ � �o �v V Y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> j1 ❑ TANK LEAKMKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> a <br /> �+O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION [E UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> �+a <br /> O ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ❑ NO AC710N TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> jm ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> Q ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK RIAT <br /> APPROPE ACTION(S) F-1EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> APPROPRIATE <br /> .Mel <br /> w6 ❑ CAP SITE(CD) a?-`EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER LOT) <br /> w d dm larwl,n/r Leh L1Catrr✓ qyi ei�YJ i� <br /> 3 o SS�s'T�nrytil— <br /> HSC F 16901 <br />