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0 • 9-2- 7 y <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGE YSERVICES PCRLCCACAGENCYUSEONLY <br /> ❑ EMERGE <br /> NO REPORT BEEN FILED? <br /> YES ❑ NO 1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> REPORT DA DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> CASE a <br /> NAME O INDIVIDUAL FILING REPORT DATE. <br /> PHONE SIGNATURE <br /> m ) <br /> w REP SENTING COMPANY OR AGENCYN <br /> ❑ OWNS PERATOR ❑ REGIONAL BOARD <br /> S LOCAL AGENCY ❑ OTHER c� �1L!'',r )_j J1, <br /> A RESS V (7J �7 IJ <br /> o , C/q gsaor <br /> STREE <br /> w NAME Cm STATE ZIP <br /> w CONTACT PERSON PHONE <br /> UNKNOWN )[L <br /> CL y ADDRESSMax- c- Fa,srnhi <br /> ({f� /� //� <br /> w 1660 IV . s/L� <br /> STATE� <br /> FACILITY NAME(IF STREET APPLICABLE) <br /> z AR OPERATOR �,I�, PHONE p <br /> ADR <br /> 9) ���-a7q S��K �DD SREE <br /> CITY <br /> y CROSSSTREETwuRry ZIP <br /> 1 <br /> a LOCALAGENCV AGENCY NAME <br /> r y CONTACT PERSON n� PHONE <br /> Q <br /> w� <br /> +� REG I) AL BOARD <br /> / I ,PHONE <br /> �J NAME QUANTITY LOST(GALLONS) <br /> Le ad <br /> mO (Z) UNKNOWN <br /> �� <br /> y <br /> ❑ UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED <br /> w E:] INVENTORY CONTROL E::] SUBSURFACE MONITORING <br /> -�7 ` ❑1 <br /> MI � G ! o Y _ Y ❑ TANK TEST ❑ TANK REMOVAL �' OTHER NUISANCE CONDITIONS <br /> < DATE DISCHARGE BEGAN <br /> METHOD USED TO STOP DISCHARGE(CHECK ALL THAT A Y <br /> w M M o o Y Y UNKNOWN REMOVE CONTENTS IJCCLOSETANKB REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK !❑"_CLOSE TANK E FILL IN PLACE ❑CHANGE PROCEDURE <br /> o VES ❑ NO IF YES,DATE <br /> Mi �.I 3p / 1 r Y ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(5) <br /> a ❑ TANK LEAK ❑ UNKNOWN OVERFILL ❑ RUPTUREiFAILURE ❑ SPILL AIS <br /> y O ❑ PIPING LEAK OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER `J <br /> ww CHECKONEONLV <br /> O CHECK ONE UNDONLY MINED SOIL ONLY ❑ GROUNDWATER ElDRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) `f <br /> V <br /> ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> Uy ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> ISg eVx loHOEGasI EXCAVATE B DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> wp ❑ CAP SITE(CD) EXCAVATE 8 TREAT(ET) ❑ PUMP 8 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> a ❑ CONTAINMENT BARRIER(CS) NO ACTION REOUIflED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> zorl��yariwn s <br /> /', S-focl�i le w aa., ba & �%•� C�iira�`r <br /> HSC a IES% <br />