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74 <br />& q,7i--41-1 o' I <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />FOR LOCAL AGENCY USE ONLY <br />❑ YES Ev REPORT BEEN FILED? YES ❑ NO <br />NERE6Y CERTIFY THAT i AM A OESIGNRTED GOVERNMENT EMPLOYEE AND THAT I HAVE: <br />REPORTED THIS INFORMATION TO LOCAL OFFICIAL PURSUANT TR SECTION 251907 OF:: <br />THE H AN SAFTY,: <br />REPORT DATE <br />CASE* <br />M1 — o `l r ._ r <br />SIGNED z ..DATE <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE x <br />IH <br />REPRESSING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD <br />COMPANY OR AGENCY NAME <br />LOCAL AGENCY OTHER <br />' !� <br />Lu <br />ADDRESS <br />J0eNf/ � rJ <br />TREFr Tarr STATE -52-0) _ ziP <br />w <br />NAME <br />CONTACTPERSON <br />cc <br />FA <br />ri r �n U S ❑ UNKNOWN <br />E'_ <br />/PHONE <br />R a <br />—w <br />ADDRESS <br />LLJ <br />S <br />' zjai-! 'P):�':2. STREET �ock46 J-.1 CRY C� STATE 05— ZIP <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />/f/ <br />t /� ] ler /PHONE +����^ /) <br />H <br />V <br />ADORE/SS <br />FI' <br />�[ <br />` �/ _ STREET `n CRY -?^/ WUNTY r J.� ' -' P <br />CROSS STREET <br />ff <br />z <br />LOCALAGENCY AGENCY NAME <br />OONTACTPER N <br />PHONE <br />r <br />U <br />1j17 <br />?A ' i ry t v7 w/�c 614 9 "lJrie-1 °N <br />{ t, 4�vt <br />1' y�C` j L/ <br />REGIONAL9OARD <br />PHONE <br />d d <br />� <br />ff <br />1 <br />/S) <br />w <br />(1 NAME QUANTITY LOST (G�`LNKNOWN <br />q <br />-> <br />Z <br />(2) <br />y <br />❑ UNKNOWN <br />z <br />DATEDiSCOVERED NOW DI VERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CO NDITIONS <br />Lu <br />2 <br />µ M 0. o �Y�� r TANK TEST ❑ TANKREMOVAL ❑ OTHER <br />9 <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />M u e o v v ❑ UNKNOWN <br />❑ REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br />0 <br />❑ REPAtR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED? <br />o <br />El YES ❑ NO IF YES, DATE <br />�j s <br />r <br />I OTHER <br />M M D v Y <br />-a <br />SOURCE OFDISCHARGE <br />CAUSE(S) <br />TANK LEAK UNKNOWN <br />❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br />9+ O <br />❑ PIPING LEAK ❑ OTHER <br />❑ CORROSION ❑ UNKNOWN ❑ OTHER <br />ww <br />h a <br />CHECKONEONLY <br />❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />z w <br />❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br />❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />o <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTIONS) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BO DEGRADATION (IT) <br />Z <br />w Q <br />('gEa FCRMMA <br />❑ CAP SITE (CD) ❑ EXCAVATE & TREAT (ET) ❑ BUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />Lu a <br />CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />❑ VACUUM EXTRACT (VE) ❑ OTHER (OT) <br />". _ I -wC7�' �. rripni <br />" /v <br />co <br />Lu <br />E5S Wl G/f �/ (fit f l ^Pr� �o �/77,wP�.1z NU pNc�i v�,n , .+J �dA�gy%mu fiat <br />� MM llimm <br />