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sr )'i _ <br /> UO <br /> U Li <br /> UNDERGROUND STORAGE TANK U AUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> YES NO YES ❑ NO <br /> REPORT BEEN FILED? ]HEREBY CERTIFYTHAT I HAVE DISTRIBUTED.THIS INFORMATION ACCORDING TO THE <br /> ❑ ❑ <br /> DISTRI LIT ON SHOWN ON THE W TRUCTION SHEET ON THE BACK PAGE Of THIS FOAM <br /> REPORT DATE CASE <br /> UM 5MI t2 v SIGNED <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SI`GNAPJRE <br /> m <br /> Lu REPRESENTING F-1OWNER/OPERATOR ❑ REGIONAL BOARD COMPAN- VY(!O�R AGENCY NAME <br /> LOCAL AGENCY ❑ OTHER 5av)v1 I IIam-alki <br /> ¢ ADDRESS <br /> WSTREET r CT' STATE ZIP <br /> Lu NAME ^ ^t r �Z 71r-;A <br /> CTPERSON PHONE <br /> zLn <br /> ¢ C,+ev1 m Prvdltll✓ ❑ UNKNOWNI�r ��f c��� (4L✓)��z�Ire 3 <br /> a a ADDRESS <br /> cc ISD .fix u no+ t'1 (fit i Yl ori IY11 <br /> w <br /> STREET CITU STATE IP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ObNY M Stlifi Fn -7 T( <br /> 0 <br /> ¢ ADDRESS <br /> g <br /> J 3�1 S. ��Yl l" S—h"��.�f" StC�� t�'1 �L11jo+kIti►�) L��ZDZ <br /> w STREET CITY C HTV ZIP <br /> ~ CROSS STREET <br /> 0 LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> wR 5kyl 3DA( vrr1 Cma onvi►SChhY1AW>k 1 bInti fbnft' qL,-,y <br /> w REGIONAL BOARD PHONE <br /> Tn (i) NAME QUANTITY LOST(GALLONS) <br /> LU O <br /> Z J EDUNKNOWN <br /> g <br /> m z (2) <br /> D— <br /> Tn ❑ <br /> UNKNOWN <br /> z DATE DISCOVERED HOW <br /> I +��7 HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w UMI s-1UI �o ( o! Ov v ❑ TANK TEST ' TANK REMOVAL OTHER <br /> r- <br /> ma DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> ¢ M o o r r UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> Lu <br /> p HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o YES [:] NO IF YES,DATE VMI 2 MI Z-o L4 o V v 3v ❑REPLACE TANK E::] OTHER <br /> � SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> L) <br /> a ❑ TANK LEAK UNKNOWN ❑ OVERFILL EDRUPTURE/FAILURE E] SPILL <br /> ti O ❑ PIPING LEAK ❑ OTHER CORROSION UNKNOWN ❑ OTHER <br /> w ww CHECK ONE ONLY <br /> 0 UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Z NO ACTION TAKEN O PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> cc <br /> cl: ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J (SEE MLK FOR WTA") <br /> a Z ❑ <br /> 0 CAP SITE(CO) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> Lu0 <br /> ¢ ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> cr ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> Lop <br /> z <br /> w <br /> 0 <br /> 0 <br /> U <br /> HSC 05(avq <br />