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r i E C <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 9 I HEREBY CERTIFYTHAT i HAVE DISTRIBUTED.THIS INFORMATION ACCORDING TO THE <br /> ❑ YESNO ❑ YES O D U IONS N IN CT N SHEET ON THE BACK PAGE O THIS FCfki <br /> REPORT DATE CASE sJ, <br /> C c� <br /> EDDRESS <br /> I S 3 v SIGNED <br /> IDUAL FILING REPORT PHONE SIGNA <br /> Lacn <br /> E <br /> G OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME/AGENCY ❑ OTHER L(111( - / r/�/ 1'SOC��%ET <br /> I <br /> ` 1 'r�STREET / ' �— . Cm !'7C I r=, /f STATE Ci l ZIP <br /> w �T,` <br /> NAME CONTACT PERSON PHONE <br /> ❑ UNKNOWN T �} ;�� OL y Attu <br /> z� C� v <br /> a-, ADDRESS <br /> � Si ci C�i Lam/ �'AL-/t�pr <br /> 2 ` I �_G ,/ CITY STATE IP <br /> FACILITY NAME(IF APPIICABIE) OPERATOR PHONE <br /> z <br /> 0 <br /> a ADDRESS _ <br /> O l� � ���-�Jr tn/7R%i/C� U//-)`� Si c.�C✓.%Gry �/ ;-i ' <br /> STREET C(TY COUNTY ZIP <br /> w <br /> rCROSS STREET <br /> AGENCY NAME CONTACT PERSON PHONE - <br /> O LOCAL AGENCY <br /> FZ-- _ <br /> Z W — I c_ Nom!T✓ <br /> w it REGIONAL BOARD PHONE <br /> y (T) NAME QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> Z <br /> Q J �� <br /> U) <br /> O( 2) <br /> :3 / 3 ® UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ VENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w I 4 [� M) oI DI 5 v v ❑ TANK TEST ❑ TANK REMOVAL © OTHER Ani. rs a'�-Qt /.- .�y e4l/�/ <br /> < DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> Q <br /> UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> Lu M D I V <br /> l Yl <br /> >O HAS DISCHARGE BEEN STOPPED T ❑REPAIR TANK ❑CLOSE TANK&FILL W PLACE ❑CHANGE PROCEDURE <br /> � ( ❑REPLACE TANK ®OTHER C'/ ^< `!In/%S a LtQ( -REWA�Mt <br /> o <br /> [gr YES ❑ NO IF YES,DATE M o Yl v <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> j< [7 ® <br /> TANK LEAK , 'UNKNOWN ❑ OVERFILL ❑ RUPTUREAFAILURE ❑ SPILL <br /> 9)v f7PIPING LEAK F-1OTHER ❑ CORROSION ® UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> Na <br /> v UNDETERMINED ❑ SOIL ONLY [—] GROUNDWATER [:] DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ia, <br /> F7NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w <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&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> (SEE wK FOR MAIb7 <br /> zF7 CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) F-1PUMP&TREAT GROUNDWATER(G ❑ REPLACE SUPPLY(RS) <br /> 00 <br /> w a Lu <br /> ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> y S)i7 COIC.1- 3 "J?r7r� c,�Cc T4.t1A`'S rl.4f- ?cr/+ ./ct� �t cadrl` LtCgT%a�j /S <br /> Z i A lfnJ��r:.�it1 I�LQ,ti�.� /?n) h�r.1:S�t� /0 -).11 atk-7 Nv:,V . <br /> w O� I-ILS (.J/ S A./ <br /> f <br /> 0 V' <br /> 5(%�- ' l.J e_�_(C-r/�i � <br /> lc7+V Oil l_` rZC= CaCZJ,.�AiC� "1 t c `�'L/42>j -= <br /> HSC 05(&90) <br />