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cqvu� + <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 YES ❑ NO 1HERESYCERTIFYTHATI HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> E] YES NO DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE q CASE i <br /> Q g, a Y $ICiNED . DATE <br /> YPHONE SIGNATURE <br /> NAME OF INDIVIDUAL FILING REPORT <br /> I <br /> O R PRESENTING ❑ OWNER/OI [:3REGIONALBOARD COMP ANYORAGENCYNAME - J� <br /> C &. <br /> LOCAL AGENCY ❑ OTHER n ', /,� ' ,G/.{ }Q �+J J //�' <br /> S ADDRESS �Y/V"��/ / V `-'�� D�.`'y c� 9.�aoa <br /> 3 1 � � � OJJY STATE ZIP <br /> CONTACT PERSON J'�l PHONE <br /> j NAME of BQ wol )453 ab1/ <br /> I <br /> N <br /> m B P ❑ UNKNOWN L <br /> y n ADD ESS9 JWIV' <br /> cg g5aq 1 <br /> 2 D J B I l LRy STATE IP <br /> STREET PHONE <br /> OPERATOR <br /> FACILITY NAME(I�PLIC�E) 969333-106 <br /> ADDRESSE 11 s'f DC/ <br /> ryX K J ✓ - J <br /> p J rl l•!' LRY COUNTY ZIP <br /> � V �D STREET <br /> W <br /> y CROSS STREET <br /> PH <br /> O LOCAL AGEN AGENCY NAME CONTACT PERSONONE <br /> =N S�. Cb p 0 s — F. H D fMet* c )��g <br /> w <br /> w p PHONE <br /> ww REGIONAL BOA D ) <br /> CL <br /> � uf G" B <br /> NAME QUANTITY LOST(GALLONS) <br /> 1 <br /> w ( UNKNOWN <br /> =w GAsru oliVK7"8F 8 ?� <br /> m=m_ ❑ UNKNOWN <br /> HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> i DATE DISCOVERED ❑ ❑ (� <br /> O Q ❑ TANKTEST ❑ TANK REMOVAL OTHER . <br /> u D D r v <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT PLY) <br /> a UNKNOWN I REMOVE CONTENTS IJ�I CLOSE TANK d REMOVE E]REPAIR PIPING <br /> M D D Y Y !/� <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK d FILL IN PLACE ❑CHANGE PROCEDURE <br /> o VES ❑ NO IF YES,DATE M M D Y V ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSES) <br /> ¢, ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> 0U ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> ww CHECKONEONLY <br /> h a <br /> U ❑ UNDETERMINED SOIL ONLY E] GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFEC ) <br /> CHECK ONE ONLY <br /> i Zx NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED E:] POLLUTION CHARACTERIZATION <br /> F ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> ❑ <br /> CHECK APPROPRIATE ACTIONS) �( EXCAVATE 8 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> a z ❑ CAP SITE(CD) � EXCAVATE 8 TREAT(ET) ❑ PUMP d TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> an 0 ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ¢a <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> o <br /> w a�,rvz,c� ovv <br /> s <br /> � H9L OS ISN% <br />