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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES 1 FOA_LOCALAGENCY USEONLY. <br /> F-1 YES NO REPORT BEEN FILED ? ❑ YES ❑ No 1 HEPEBYCERTIFYTHATt HAVE DISTRIBUTED TH151NFORMATION ACCORDING TO THE <br /> DISTREUTION SHOWN CN THE.INSTRUCTION SHEETONSHE.BACK.PAGE Of THIS.FORM <br /> REPORT DATE M - CASEA - <br /> MI 4 e r SIGNED cz <br /> DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE - <br /> l�i .ra <br /> w REPRES TNG F'] OWNERIOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> aLOCALAGENCV ❑ OTHER <br /> a ADDRESS / p L _ �� <br /> !/ Y� N Sccn ✓tYec er %a7w ViVC /c�Ul. <br /> srRffr em a AW zw <br /> NAME LLGS -- - - CONTACTPERSON PHONE - <br /> v' ¢ _7u ❑ UNKNOWN L /Z/->L <br /> f � f ,� ( � g c(v'S67 <br /> ii ¢ ADDRESS♦ � �r C 6.- 7'Z/_>L v' / 4' 5 _o3CG � <br /> SfRfET cm STATE ZIP <br /> FACILITY NAME (IF APPLICABLE) OPERATOR �PHONE <br /> UADDRESS C3% e? <br /> Cwt L 4 cS G �d�T/� + <br /> w L S f <br /> STREET cOUNIV ZIP <br /> — CROSS STREET - - <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> wU <br /> wwR ZONAL BOARD <br /> O - PHONE <br /> (1) NAME QUANTITY LOST (GALLONS) <br /> w <br /> ¢ J NKNOWN <br /> y Oj (2) Q- -IId rT� 7 <br /> T/ff/ rta1nK l�2Yv� DV e ✓ - ( - 91 � WUNKNOWN <br /> �- DATE DISCOVERED - HOW DISCOVERED ❑ <br /> lPVrNTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> s M 6 I l / ❑ TANKTEST TANK REMOVAL ❑ OTHER <br /> M o o r v <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> NKNO <br /> M M D o v v UWN ❑ REMOVE CONTENTS ❑ CLOSE TANK & REMOVE - ❑ REPAIR PIPING <br /> 0 HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE <br /> U <br /> o ❑- YES ❑ NO IFYES, DATE MI V ❑ REPLACE TANK ❑ OTHER - <br /> 01 y <br /> SOURCE OF DISCHARGE M CAUSES) _ JJyJyJ7777JJMJMJRRRR <br /> ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ E/FAILURE ❑ SPILL <br /> w0 ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w CHECK ONLY - <br /> O � UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKINGWATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w � ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> - ON ❑ REMEDIATIONPLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <br /> a z I�avMran oer..sl <br /> O O ❑ CAP SITE (CD) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNOWATER (GT) ❑ REPLACE SUPPLY (RS) <br /> w0 <br /> a ❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED INA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENTSOIL (VS) <br /> ¢ <br /> ❑ VACUUM EXTRACT (VE) ❑ OTHER (OT) / �r <br /> We // .Ev �+ C¢ rs!L fo G �-�= a.. rw <br /> w <br /> e ,..�fs D GC [L->(c-...-a c.c.s<�+. 4 r f e� G �`( f4s /a c -g !L. <br /> f <br /> U <br /> Nsc v` 13'9% <br />