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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL'AGENCY USE ONLY F__1 YES ❑ No REPORT BEEN FILED ❑ YES ❑ NO 1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE REPORT DATE DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE 13ACK PAGE OF THIS FORM CASE x M M vSIGNED DATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE �. m REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME g ❑ LOCAL AGENCY ❑ OTHER cl..rcle K ato-T*eS IInC.. Q [ADDRESS STREET CITY STATE ZIP w NAME CONTACT PERSON PHONE m Z "✓`i e:i ❑ UNKNOWN i a a ADDRESS Lu AZ 8987: STREET CITU STATE ZIP FACILITY NAME(IF APPLICABLE) OPERATOR PHONE o -Cle K Store #,8b7.1 ,.rn e K 6tare� .)_riC ADDRESS U w STREET CITY COUNTY ZIP CROSS STREET O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE z Z w T ¢� xin County .. 5-3409, w O w w REGIONAL BOARD PHONE J 0 (L a ( , LU (1) NAME QUANTITY LOST(GALLONS) 0 Z J ❑ UNKNOWN m z (Z) D- u ❑ UNKNOWN Z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS w MI MI D D v v ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER , m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) a_ cr} a UNKNOWN F__]REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING w M M D D Y Y HAS DISCHARGE BEEN STOPPED? E::]REPAIR TANK a CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE U ❑ YES ❑ NO IF YES,DATEM MI D V V ❑REPLACE TANK E:] OTHER � D SOURCE OF DISCHARGE CAUSE(S) Q j F TANK LEAK ❑ UNKNOWN OVERFILL RUPTURE/FAILURE ❑ SPILL N v ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER wwa CHECK ONE ONLY U ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER [:] DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY w F__] NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION I a:N ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) J (SEE BACK FOR WTALS) a Z ❑ 00 CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) w 2< CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) fit 14et z js� ve C as :Y x, suuE+ G:�t'ei c s E F35L �.:3 L t� K SC Vj_k. .. `r -xl 3IYv SGi.ycawra .nd male repairs. SECOR Environmental will determine it actual Leak 0 ,°-•f-.; ,:.-_era and decide appropriate remedial activities it needed. HSC 05(S"