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dl - u-� g <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES "FOR LOCALAGENCY'USE ONLY. <br /> ❑ VES NO REPORT BEEN FILED? <br /> � YES Np 1HEREBY CER1lFYTHAT I HAVE DISTRIBUTEDTHIS INFORMATION ACCORDING TOTHE <br /> REPORT DATE DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> �j .v/� CASEi <br /> `� 5y I .J © Y SIGNED DATE. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> REPRESENTING O OWNER/0TOR ❑ REGIONAL BOARD COMcPANY OR AGE NAME <br /> S LOCAL AGENCY ❑ OTHER V, �, C _ <br /> ¢ -364 e, Wvbt � Ave, <br /> nw" �S CUR d <br /> Asa <br /> C'm �^TE ZIP <br /> j NAME,. /� ''}'� ,� ^ CONTACTPERSON PHONE <br /> i k F-PK.B c&' 4 Yn PG!" 1"` ❑ UNKNOWN LAilk <br /> (oZ D�s <br /> O a <br /> ADORESS <br /> A veA , �Sfo C Fkgt)w c q � <br /> STREET CITY STATE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> RAI B Gcuu6hukdz (.Vq) X640-176/ <br /> ADDRESS <br /> 7/5 N,, H g s�; foc kY, <br /> CITY w r <br /> y CROSS STREET <br /> i y LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w w REG NAL BOAP <br /> 0 vPHONE .� <br /> w (0) NAME jy QUANTITY LOST(GALLONS) (� <br /> w H-G H - D UNKNOWN O <br /> UNKNOWN <br /> i DATE DISCOVERED HOW DLSCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 2 5. 5.1 ©Y l Y ❑ TANK TEST \TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M D UNKNOWN FIrMOVE CONTENTS CLOSE TANK&REMOVE OREPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED? �❑^REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o VES ❑ NO IFYES,DATE M Y Y ❑REPLACE TANK E]OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> =a ❑ TANK LEAK x UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> NG F-1PIPINGLEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w gw CHECK ONE ONLY <br /> F ❑ UNDETERMINED *tKSOIL ONLY E:] GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w� NO ACTION TAKEN ❑ PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED O POLLUTION CHARACTERIZATION <br /> jq ❑ 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) Q EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) Q ENHANCED BIO DEGRADATION(IT) <br /> J I�eK.WioETNH, <br /> 0 4 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> wa ❑ CONTAINMENT 13ARRIER(CB) NO ACTION REQUIRED NA) ❑ TREATMENT AT HOOKUP HU) ❑ VENTSOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) 39-OTHER(CT)_4i f� <br /> HSC QS(fl9% <br />