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UNDERGROUND STORAGE TANK UNAUTHORI D RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OFEMERGENCVSERVI s❑ FOR LO 'AGENCY.USE ONLY <br /> VES NO REPORT BEEN FILED 7 <br /> ❑ YES NO IHE YCE FYTHATI HAVE DISTRI UXDTH§JNF MATION ACCORDING TOTHE <br /> R PORTDATE � � DI RIBU ��IXJ THE IN EBACK P GE��SFORM <br /> CASE< <br /> r �� - <br /> S DATE <br /> A FINDIV�UAL FILINGREPORT PHONE. jNr <br /> QQQPRESE ❑ OWNERIOPERATOR ❑ REGIONAL BOARDYR gGENLOCALAGENCY ❑ OTHER �J['�7' hF <br /> 9TRFET C" gATE / JfiV <br /> m tDRE.. <br /> CONT TPERSON PHONE p <br /> i UNKNOWN <br /> asCf/ <br /> I W, 1'�� Z §c 9 <br /> STATE p� <br /> FACT NAME(IF APPLICABLE) OPERATOR PEON <br /> I <br /> ADDR�Z/ /Y �� ✓' ✓/v v"V <br /> 3 <br /> y <br /> CROSS <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON <br /> PHONE <br /> w <br /> w w REGIOW BOARD / <br /> PHONE <br /> NAME ` <br /> QUANTITY LOST(GALLON <br /> z> <br /> mp � UNKNOWN <br /> N <br /> UNKNOWN <br /> W DATE DISCOVERED 9 �/7 HOW DISCOVERED ❑ yENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> M M Dp /y v y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHA <br /> / (CHECK ALL THAT APPLY) , <br /> w o y y <br /> /UNKNOWN ❑REMOVECONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> HAS DIS ARGE BEEN STOPPED 7 <br /> cR q ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> p YES ❑ NO IF YES,DATE /M M 0. / ❑REPLACE TANK ❑OTHER <br /> y y <br /> � SOURCE OF DISCHARGE CAUSE(S) _�` <br /> a ❑ TANK LEAK UNKNOWN ❑ OVERFILL TURE/FAILURE ❑ SPILL <br /> w O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> yww CHECK EONLY <br /> U UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z Z NO ACTION TAKEN PRELIMINARY SITE <br /> w ❑ ❑ PRELIMINARY SITE AASSESSMENT UNDERWAY SUBMITTED POST CLEANUP MONITORING CHARACTERIZATIONPOLLUTION <br /> LEAK BEING CONFIRMED DPROGRESS <br /> �y <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> Iat vcxwnnFrAup ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> az <br /> w o ❑ CAP SITE(CD) ❑ EXCAVATE B TREAT(ET) ❑ pUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(q5) <br /> ca ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) F-1 OTHER(OT) <br /> r <br /> HSC m("o) <br />