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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE AK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOA LOCAL AGENCY USE ONLY <br /> ❑ YES ❑ NO REPORT BEEN FILED 7 <br /> ❑ YES NO 1 HEREBY CERTIFYTHAT 1 HAVE DtSTRIW EDTHIS INFORMATION ACCORDING TO THE <br /> REPORTDATE CASEa r�+� D�� � STRUCtION,SHEErONTHEBACKPAGEOFTHISFORM <br /> r '` SIGFIED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> CD <br /> REPRESENTING1G r S G <br /> Lu ❑ OWNERIOP OR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> g ❑ LOCAL AGENCY ❑ OTHER „_ _ r� <br /> ¢ ADDRESS W�/J <br /> 'TRS' o 10038 <br /> CRY ' <br /> 1R^ceS�q <br /> STATE � <br /> mw NAME CONTACT ON PHONE 1_ l' <br /> z¢ \/`�1YJ �C�` J Lj .❑ UNKNOWN <br /> yQa ADDRESS <br /> Lu <br /> Cc <br /> STREET CRY STATE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE v <br /> w< ADDRESS �•/ <br /> 0o STREET CRY LG A'\ <br /> h CROSS STREET C� Coutm <br /> CT 1 <br /> i LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> Lij <br /> LLJcam, Ja v w Coy �Sa� ��1� c)NJ <br /> w w REGIONAL BOARD <br /> a I PHONE <br /> wt1) <br /> U w NAME OUANTFTY LOST(GALLONS) <br /> '=a- c� ° S" —4 ❑ UNKNOWN <br /> y> m <br /> N <br /> ❑ UNKNOWN <br /> Z DATE DISCOVERED a HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> LlC` ❑ TANK TEST ❑ TANK REMOVAL <br /> p r r ❑� OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE <br /> m (CHECK ALL THAT APPLY) <br /> g <br /> w u p ❑ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK 8 REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK d FILL IN PLACE ❑CHANGE PROCEDURE <br /> p ❑ YES ❑ NO IF YES,DATE ` q REPLACE TANK OTHER <br /> � SOURCE OF DISCHARGE CAUSE(S)U w <br /> `) I❑ TANK LEAK <br /> AU <br /> o a I� UNKNOWN n OVERFILL I—� <br /> o I [ PTURElF41LU?E eon i <br /> N ❑1 <br /> PIPING LEAK ❑ OTHER ?v CORROSION ❑ UNKNOWN <br /> OTHER <br /> Lu w CHECK ONE ONLY <br /> v ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER •(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z� <br /> Z ❑ NO ACTION TAKEN <br /> w ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERQATION <br /> j y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> v ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLRED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> < ISM WAX rw ucrum ❑ EXCAVATE E DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> 0 0 ❑ CAP SITE(CO) ❑ EXCAVATE d TREAT(ET) PUMP&TREAT GROUNDWATER G <br /> Lu ❑ t T)❑ REPLACE SUPPLY(RS) , <br /> Q< ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION RE IRED(NA) E] TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(V3) <br /> ❑ VACUUM EXTRACT(VE) � OTHER(OT) (�� l,�� <br /> z1 \ a Sw rt,,, . <br /> A ai GIbS S. e A111 <br /> VA" a -4i� � w,Z wau,� uja, l tjJ4, <br /> HSC 05(OW <br />