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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONT WI IORT <br /> EMERGENCY HhS STATE OFFICE OF EMERG NCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED❑ <br /> YES NO YES NO I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE� � ❑ , <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACOAGE OF THIS FORM. <br /> REPORT <br /> ©DATE <br /> ] (\ a CASE i <br /> 0 /� 0.3 <br /> � <br /> d -1 � v cV -.Q O� SIGNED - 1"I.'DATE <br /> NAME OF INDIVIDU FILING REPOR PHONE SIGNATURE - I j j�� VI E.. <br /> m <br /> (l�� ) to - Sa U� � <br /> ow REPRESENTING O NE TOR ❑ REGIONAL BOARD COMPANY OR AG NCY NAME ^1 <br /> 2¢ ❑ LOCAL AGENCY ❑ OT <br /> � <br /> ¢ ADDRESS 9eo;L <br /> 1' STREET CRY 1 , STATE ZIP 0 2, <br /> w NAME CONTACTPERSON PHONE <br /> zJ /1 <br /> (-wCo - ❑ UNKNOWN <br /> as a ADDRESS <br /> W <br /> w <br /> cr STREET CRY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> RRCo �C0.c 2\8� \�\AAs �F}NC� b (2a9 ) 941 Zbg� <br /> ADDRESS C C p �, 9S2o�1 <br /> O /1 1 • STREET ` `CJS\�V�c CRY I > T ZIP <br /> w L,\'L SrLX.\^l U N COVNTY"O� V 1''N <br /> CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w <br /> w w REGIONAL BOARD PHONE <br /> js'tip <br /> U) (1) NAME QUANTITY LOST(GALLONS) <br /> w p <br /> U w <br /> ¢J PirUNKNOWN <br /> CO Z (2) <br /> ❑ UNKNOWN <br /> z DATE DISCOVEIRED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> OMI �I ` DI CI Y S Y ❑ TANK TEST ❑ TANK REMOVAL ® OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAF APPLY) <br /> m <br /> Q ( UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK 8 REMOVE ❑REPAIR PIPING <br /> w Y M D Y <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK d FILL IN PLACE ❑CHANGE PROCEDURE <br /> vN�.NoW N %-Q _ Ccrm e+�►ts <br /> o ® YES ❑ NO IF YES,DATE MI J D Y Y ❑REPLACE TANK OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> 2 ❑ TANK LEAK UNKNOWN n OVERFILL ❑ RIJPTUREJFAILURE r� SDILL <br /> O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ® UNKNOWN ❑ OTHER <br /> N wa CHECK ONE ONLY <br /> O�- ® UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z c ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION J\ <br /> w <br /> fr <br /> I ❑ LEAK BEING CONFIRMED © PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O rn ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) C <br /> G Z Isrf e,vx rrn o�T.usl I <br /> o O ❑ CAP SITE(CD) ❑ EXCAVATE b TREAT(ET) ❑ PUMP d TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Q< ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) <br /> c �� ✓OC � Q��V\G� c � �G5�%�t¢OR . <br /> CLA <br /> �, ro <br /> w Ogoj\ � 0161\ � f'moo � UL�tq% keineto akfQAIM\ e Wk � VR2• p�Ie�sZs <br /> esso <br /> o <br /> Ov(L, Ptl•Twakk- �q.5�b�-�tYC rev Jr '1�-�\ row -C \ '�< S S �` <br /> r+sc 05 lagol <br />