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UNDERGROUND STORAGE�rAK UNAUTHORIZED RELEASE(LEAK)ONTAM1NATIO T` <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES i OR'LOCAL'AGENCY USE.QNI Y ' <br /> REPORT BEEN FILED T <br /> []-YES HO ❑ YES NO AHERESYCEMV;tHAtt.tiAYEt3ISTRi3DTtIfSINFflRMATifidt4f lDItGTO <br /> lltSTR1Bt! SHOWSHEET t7NTHE BACi ASE&THISF{]I{�1 j <br /> REPORT DATE CASES• <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATU <br /> 446 9 <br />` REPRESENTIN[i. ., ❑ OWNEROPERATOR ❑ REGIONALBOARD. PAANNY+ORA,rGE,,, E I <br /> LOCAL AGENCY O <br /> .ADDRESS. �CD•� � <br /> Si331�T env STATE ,ZIP � <br /> w NAME CONTACT PER ON + PHONE <br /> z fC ❑ UNKNOWN <br /> ADDRESS i� G/4 <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE: <br /> a <br /> ADDRESSL'�' <br /> t� G,1y <br /> GtTY AP- .: <br /> CROSS STR T <br /> .: <br /> LOCALAGENCY AGENCY.NAME, CONTACTPERSON PHONE <br /> dl REGIONAL E30ARD PHONE 1 <br />! it <br /> m (1) NAME OUANTITYLOST(GALLONS) <br /> UNKNOWN ; <br /> Y' <br /> N M UNKNOWN <br /> DATE DISCOVERED) HOW DiSC.OVERED ❑ INV NTORY CONTROL ❑ SUBSURFACE.MONITORING ❑ NUISANCE CONDITIONS <br /> TANK TEST TAIq(REMOVAL OTHER <br /> e: DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> p„ KNOWN r7REMOVE CONTENTS CLOSE TANKS REMOVE: ❑REPAIR PEPINC) , <br /> HAS DISCHARGE SEEN.STCPP07 <br /> . ❑REPAIR TANK (-CLOSE j A6.FILL.IN PLACE ❑CHANGE PROCEDURE. <br /> YES ID NO IFYES,DAfE Y �❑REPLACE3TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> pu�E TANK LEAK . USN F OVERFILL ❑ RUPTUAE FAILURE: ❑ Sm <br /> rT+ 0PfF9NCiLEJ1iC U. OfI R. ❑ CORROSION UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> ❑ UNDETERMINED ❑ SQ14ONLY ❑ GROUNDWATER DRINKING WATER •(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHRX:ONE:ONLY <br /> z+� NO ACTION TAKEN. ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CKMIWMR17AMN <br /> w C LEAK BEINd.CONFIRIIED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ OSTCLEANUPMONITORING:IN-PROGRESS <br /> C REMEDIATIONA-0 C3 Ct$>:CLOSED4EANUPOOMPLETEDORUNNECESSA" Q 'f;EANUPUNDERWAY <br /> CHECK APPROPRIATE ACTIONS) ❑ O(CAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ❑. .ENHANCt-3?.BIO DEGRADATION(IT) <br /> :ISYSt ClW�tf6FlCRh'K31. <br /> CAP SITE(CD) ❑ EXAVATEA TREAT(ET) ❑ PUMP A TREAT GROUNDWATER af)❑ RE AcE SUPFit`C:(RS) <br /> CD CONTAINMENT BARRIER(CB) ❑ :t+io:ACTKtrI REtlRNRED aVA} r7TREATMENT AT HUVIRrPIHUf V84TSOIL(VS) <br /> ❑. <br /> VACUUMiEXTRACT(VE) GTHERIOT). <br /> i <br /> I .. . • <br />