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) <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY ' <br /> REPORT BEEN FILED 7 <br /> FIVES '� NO � YES Q'NO 1HEPEBY CERi1FY7HATt HAVE DISTRIBUTEDTHIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE 1 - CASE * <br /> o � n 0 <br /> M 9mi (0 3Y ::.SIGNED DATE <br /> C NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATA2 <br /> I m Dina. fl1-�xte, ( sm ) Rax - 6Itpcs '1 U' n.a., <br /> RE,P�RE{skNTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME. ^ ,.� o �/�j� <br /> a LJ LOCAL AGENCY ❑ OTHER UTC. V) �'D�') E��'�^^ "`` A <br /> ADDRESS <br /> 304E Weber 3r4 Fjoor (J�farl Ck <br /> STREET CITY STATE ZIP <br /> NIA'MEC /y {t� (� �T� 1 �mDU� CONTACTPERSON PHONE <br /> tl <br /> w � UbPc r�._ UNKNOWN ( g ► O ) VE1 'J J / "✓V <br /> a < ADDRESS <br /> 3pl I A u STREET ! etc- Zao A (610 ra olls C+A RI301 <br /> FACILITY NAME (IF APPLICABLE) OPERATOR S PHONE <br /> o <br /> ADDRESS <br /> s IyR E Char+ VVL141 b1alei ?n 54* loac�uin q5w � <br /> W COUNTY 2IP <br /> G CROSS STREET <br /> Z LOCALAGENCY AGENCY NAM CONTACTPERSON PHONE <br /> _ � nS i� vivQnm ►tuUl� Bina mut-� cel ) �{ uK <br /> w w REGIONAL ErOARDPHONE <br /> CunhaPVal M4 Piard ( gl (o ) 255 -3115 <br /> NAME QUANTITY LOST (GALLONS) <br /> Z w J <br /> < � UNKNOWN <br /> m o (2) <br /> z ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED O INVENTORY CONTROL ❑ SUBSURFC�AC,�YYE,�,�M,,O,,,�N�IIa�TOR-I/NG ❑ NUISANCE CONDITIONS <br /> w DM MI D DI tY r ❑ TANK TEST ❑ TANK REMOVAL OTHER <->"'�•`/^s' dWYJ Y <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> PEJUNKNOWN ❑ REMOVE CONTENTS O CLOSE TANK & REMOVE ❑y 'FiEPAIR PIPING <br /> M M ol ol Y V <br /> p HAS DISCHARGE BEEN STOPPED Y ❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE <br /> U <br /> o ❑ VES ❑ NO IF VES, DATE M M DI DI Yl V ❑ REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢ � ❑ TANK LEAK ©UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE O SPILL <br /> yO ❑ PIPING LEAK ❑ OTHER ❑ CORROSION Q1INKNOWN ❑ OTHER <br /> w CH�E�CKKONEONLY <br /> vi <br /> O UNDETERMINED ❑ SOILONLY O GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> zw [L�NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> Qa ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ON ❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> I�e�cx wAOEn.�.91 EXCAVATES DISPOSE (ED) <br /> ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <br /> og ❑ CAP SITE (CD) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (OT) REPLACE SUPPLY IRS) <br /> mo ❑ CONTAINMENT BARRIER (CB) F--] NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) E] VENTSOIL (VS) <br /> w < <br /> ❑ VACUUM EXTRACT (VE) ❑ OTHER (OT) <br /> Aber <br /> w <br /> Q <br /> U <br /> HSC 0.5 (&90) <br />