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UNDERGROUND STORAGE T K UNAUTHORIZED RELEASE (LEAK) / KiNTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />REPORT BEEN FILED <br />` FOR LOCAL AGENCY USE ONLY <br />❑YES NO ❑YES ❑ NO <br />1 HEREBY CERTIFY THAT) HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br />DISTRIBUTION HOWN ON THE �7STRUCT N ET ON THE BACK PAG OFTpIS FORM <br />RE/SPORT DA <br />CASE •—\{`��(/�J'��/�tsl <br />9 <br />A �! ql7 <br />SIGNED V—�TE. <br />NAME OF INDIVIDUAL FILING REPORT <br />Y <br />PHONE <br />s24 �Sz� �o� <br />SIGNATURE <br />m <br />w <br />REPRESENTING ® OWNE PERATO REGIONAL BOARD <br />COMPA OR AGENCY NAME <br />S <br />❑ LOCAL AGENCY ❑`y' OTHER//' <br />A ^ WA <br />A/gyp <br />ADD SS IV (� cm l�,7✓ v f sTAre <br />4A/ <br />WA'��///} <br />j <br />NAME)/2 <br />7✓ <br />CONTACTPERSON <br />PHONE <br />ao <br />a <br />\ /�/ VI [ UNKN�O,/.WJNr/ <br />hi <br />a <br />D: <br />AV///`�I <br />(/. M❑ <br />ADORES,$ O V v t /- / 1 we A //l-/Y/L� 9 <br />/n A <br />STREET cRy / 1 r ` /5 CAsTATE (p �� <br />FACILIttNAME F APPLICABLE)� <br />II ��•//JJ <br />OPERATOR���� �0 <br />o <br />ADDRESS <br />642 o •A/% SRE ��CR/AAA/A-�9� <br />CWNTY ZIP <br />m <br />CROSS STREET <br />�LG r <br />° <br />LOCALAGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />� N <br />z W <br />w O <br />) <br />w <br />REGIONAL BOARD <br />PHONE <br />as <br />m <br />0 <br />(1) NAME QUANTITY LOST (GALLONS) <br />W <br />UNKNOWN <br />m ° <br />m� <br />(2) <br />m <br />❑ UNKNOWN <br />i <br />DATE DI BRED //-� �//� ✓// HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITOR�G ❑ NUISANCEC DITIONS <br />O <br />M vo / y 1 v ❑ TANK TEST ❑ TANK REMOVAL ® OTHER/ <br />m <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br />M o y y UNKNOWN <br />❑ REMOVE CONTENTS ❑ CLOSE TANK & REMOVE ❑ REPAIR PIPING <br />w <br />U <br />❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE <br />HAS D CHARGE BEEN STOPPED 7 <br />o <br />VES ❑ NO IF YES, DATE <br />tj <br />E::]REPLACE TANK E:]OTHER <br />MI D Y V y <br />SOURCE OF DISCHARGE <br />CAUSES) <br />¢j <br />❑ TANK LEAK❑ UNKNOWN <br />❑ OVERFILL ❑ RUPTUREIFAILURE E]SPILL <br />a <br />mO <br />PIPING LEAK ❑ OTHER <br />❑ CORROSION ❑ UNKNOWN ❑ OTHER <br />ha <br />CHECK ONE ONLY <br />° <br />❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />wZ <br />❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />�y <br />❑ LEAK BEING CONFIRMED ❑ PRELIMINARYSITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />° <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <br />(S WK.Id10El ) <br />o D ❑ <br />CAP SITE (CD) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY IRS) <br />a <br />❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br />m <br />2 <br />z <br />W <br />E <br />f <br />HSC W (8 OI <br />�7 <br />i7 <br />3 <br />37 <br />