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UNDERGROUND STORAGE TAI JNAUTHORIZED RELEASE (LEAK)/C TAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ <br /> YES NO <br /> REPORT BEEN FILED 7 YES NO <br /> I HEREBY CERMTHAT}HAVE DISTRBUTED.THIS INFORMAT)ON ACCORDING TO THE❑ � <br /> DISTRIBUTION SHOWNON THE NISTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. <br /> REEPORT DATECASE S <br /> V uI u� rl r SIGNED DATE <br /> NAME OF I IVDUAL FII REPORT PHONE SIGNA R <br /> 6 Ae� <br /> m <br /> w REPRESENTING ER/OPERATOR ❑ REGIONAL BOARO COMPANY OR AGENCY N <br /> ElLOCALAGENCY OTHER C6 <br /> R <br /> S <br /> w- Aooaesszrrt, A-�� <br /> Ly NAME CONTACT PERSON `PHONE <br /> y� _O El _ <br /> 0 5 AbdREiS <br /> a <br /> w <br /> STREET CRY STATE <br /> FACILITY NAME(IF APPLICABLE) OPETO dPHONE <br /> Gj / -y <br /> VQ \OCG/��7a/r UV�� <br /> 4 <br /> t ADDRESS <br /> U ` <br /> y CROSS STREET <br /> p LOCAL AGE AGENCY NAME CONTACT PERSON PHONE <br /> z Lu <br /> Lu -iFEIONAL B PHONE <br /> y (II NAME QUANTITY LOST(GALLONS) <br /> o ❑ UNKNOW" <br /> w <br /> m 3 (� <br /> D ❑ UNKNOWN <br /> z DATE DISCOVERED 7C HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITWI NUISANCE CONDITIONS <br /> w y o 7,1 r ❑ TANK TEST ❑ TANK REMOVAL OTHER <br /> 3 <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT PLY) <br /> UNKNOWN ❑REMOVE CONTENTS CLOSE TANK a REMOVE ❑REPAIR PIPING <br /> > HAS DISCHARGE01 Yl BEEN STOPPED? ❑REPAIR TANK !!❑CLOSE TANK a F IN PLACE ❑CHANGE P ocEDURE <br /> 9 YES ❑ NO IF YES.DATE ❑REPLACE TANK �OTHER <br /> O y Y r <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> �c�` ❑ TANK LEAK NKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE SPILL <br /> vOi U ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> y aw CHECK ONE ONLY <br /> U UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> Lu <br /> ❑ LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> U N ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J MR 6K PM DVALM <br /> w4 ❑ CAP SITE(co) ❑ EXCAVATE&TREAT(ET) ❑ PUMP 6 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ❑ CONTAINMENT BARRIER(CB) ElNO ACTION REOUIREDTREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> < ❑ VACUUM EXTRACT(VE) OTHER(OT) <br /> G <br /> w <br /> }sS�( <br /> V <br /> HSC 05(&W <br />