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UNDERGROUND?�CY S STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CON TAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OFEMER ❑YES ryp REPOgTBEENFILED7AGENCY USE ONLY NcrSERWCEs FOR LOCAL REPORT DATE YES ❑ NO 'HEREBY CERTIFYTHAT i HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE. ^• RIR ^_L° /° �j0 CASEY DISTUTIpN NQV THE INWUCTIO SHEET ON THE BACK PAGE OF THIS Pm,, M M 1 (•1� ,. RIB ON. H7O IN m •w r w REPRESENTING ❑ OWNER/( S LOCAL AGENCY ❑ O7HER w � ADDRESS _ ❑ REGIONAL BOARD IDDgE55 iJ ❑ UNKNOWN a ADDRESS/ r STflEET v Fa CROSS STREET c,/�� i LOCAL Al;Erla �wL AGE Y NAME w� REGIONAL BOAR a< y ry) (2) i IUA DISCOVERED w e C PHONE I �,u, �., �•o ��s c,ae9�9 p�— ,/ L PHONE ( � p MI M� v ° of �y �r �---� ❑ TANK TEST INVENTORY Opry7RpL TANK REMOVAL ❑ --� '� UNKNOWN 1 SUBSURFACE MONITORING NUISANCE a DATE DISCHARGE BEGgN a METHOD CONDITION OTHER ^\ + M D D Y y UNKNOWN USED TO STOP DISCHARGE (CHECK ALL THATA pLy) ❑ REMOVE CONTENTS p HAS DISCHgRGE BEEN S70PPED w ❑ O "j ' p VES NO IF VES, DATE ❑ PUMP d TREAT GROUNDWATER (GT) ❑ CLOSE TANK 8 REMOVE V ❑ O REPAIR PIPING CLOSE TANK p( MI uI ° �EEDITAIK d FILL IN PLACE CHANGE PROCEDURE SOURCE OF v . DISCHARGE ANK ❑OTHER_ L_' PIPING LEAK + CHECKONEONLY ❑ UNDETERMINED �oxr ❑ NOACTK)NTAKEN il'CI LEAK BEING CONFIRMED ❑\ REMEDIATK)N PLAN ❑ UNKNOWN ❑ OTHER ❑ RUPTURE/FAILURE ❑ SPILL ❑ UNKNOWN ❑ OTHER SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUgLLV BEEN AFFECTED) ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMTFTED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POLLUTION CHARACTERIZATION ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ POST CLEANUP MONITORING IN PROGRESS ❑ CLEANUP UNDER ❑ 'O1 pET""I CAP SITE ❑ ❑ E%CAVATEd DISPOSE (ED) EXCAVATE WAY ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED ❑ CONTAINMENT BARRIER (CB) ❑ TREAT (ET) NO ACTION ❑ PUMP d TREAT GROUNDWATER (GT) ❑ BIO DEGRAp ATION(IT) ❑ VACUUM EXTRACT (VE) REQUIRED INA) ❑ TREATMENT AT HOOKUP HU ( 1 ❑ REPLACETSDILIVS) (RS) VENT SOIL (VS)