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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES ❑ NO REPORT BEEN FILED 7 ❑ YES ❑ No .I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. <br /> REPORT DATECASE a <br /> M M Y SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> m <br /> LLJ REPRESENTING ❑ ❑ COMPANY OR AGENCY NAME <br /> OWNER/OPERATOR REGIONAL BOARD <br /> ¢ <br /> R ❑ LOCAL AGENCY ❑ OTHER t-J'2c C'le K <br /> cc ADDRESS <br /> STREET CITY STATE ZIP <br /> LU NAME CONTACTPERSON PHONE <br /> J <br /> m <br /> Z Ae K ,°Ay L� ,, ❑ UNKNOWN 11. �_4 <br /> COL a ADDRESS <br /> co <br /> Lij <br /> STREET CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> z - K 1 x� :role K Inc. <br /> 0 <br /> a ADDRESS <br /> U <br /> of Ltl KT qYs. ban a tiu <br /> W STREET CITY COUNTY ZIP <br /> CROSS STREET <br /> Z LOCAL AGENCY AGENCY NAME CONTACT PERSON 1, PHONE an <br /> q g <br /> w U \ / <br /> w w REGIONAL BOARD <br /> 0 PHONE <br /> J 1 <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> LU O <br /> Q R.�t�k ��.,�.4.€.dtA �.i8i.. UNKNOWN <br /> F <br /> rul z (2) <br /> C/) <br /> ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> W MI MI DI DI Y Y ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> m ❑ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> LU M M D D Y Y <br /> p HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK 0 CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> N YES NO IF YES,DATE REPLACE TANK OTHER <br /> ❑ M MI D v Y ❑ ❑ Sailtai i a1r_i:iBi�..�i14 ; <br /> LD Lij SOURCE OF DISCHARGE CAUSE(S) <br /> 1< ❑ TANK LEAK F7 UNKNOWN F-1OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> U)v 0 PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> a CHECK ONE ONLY <br /> O ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER •(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z ❑ NO ACTION TAKEN 0 PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ti0 LEAK BEING CONFIRMED F7PRELIMINARY SITE ASSESSMENT UNDERWAY E] POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J (SEE BACK FOR DETAKS) <br /> a z ❑ <br /> 00 CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w< ❑ CONTAINMENT BARRIER(CB) E] NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) &ks <br /> z Jam+ A.4 0"A.. +u iirt y Gt:i i +GY C4��.tae> • 4.i i E3 Sv:tll i t4f: FF�i .tl .i3aLisriti .s{ r C <br /> And mmkke repairs, bk. will. determine ix actual it::ak <br /> o iccurrea anL Kiecide appropriate eriiedi ai activities ii needed. <br /> HSC 05(MO) <br />