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c)9 . u7-8 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/C NTAMINATION SITE REPORT <br /> HAS STATE OFFICE OF EMERGENCY SHRIACES FOR�.00AVAGO CY ISE lltY <br /> EMERGENCYYREPORT BEEN FILED 1 <br /> tHE�.'CEATFIITl�AT11tAYEDtE1fl7?HISi1FCR1AA110![At�ORDNIGTO�tE <br /> No <br /> YES NO '� C3 ols�`aeur�a+sF+ownari n��rA�criop s�Ei'ON n+e sac PAc�aFnusa . <br /> T DATE� 5 � ( CASE a <br /> � .. .. . DATE. ..::.. <br /> j:M4MOUAL FILING PHONE SIGNATURE <br /> �6 <br /> } <br /> ol <br /> rCOMPANYOaTMIGpWNEagpEaATOa ❑ REGIONAL80ARDS. �. �SCAL AGENCY ❑ OTHER <br /> 12 —ADDRESS Ave. 3 ctsoloa <br /> W NAME OONTACTPERSON P PHONE <br /> J V � ) <br /> ADDRESS ❑UNallowrlN i awl a__ sSfO C. , t.- C 1 g l cJ1�KJ <br /> and <br /> ARM <br /> � • a / p <br /> FACILITY NAME pF APw.I000-. , <br /> ADDRESS <br /> r� , iPHONE <br /> le- <br /> stdS-f�oGf(�-o�� S�� <br /> ZIP <br /> CR08S STREET <br /> s� <br /> p LOCAL . ��� NAY ��ECONTACT PERSON . PHONE <br /> w°' S.t. — ( ) <br /> REGIONAL BOARD v PHONE <br /> NAME QUANTITY LAST GALLONS) <br /> (" ?� IUNKNOWN S <br /> o� •� X ❑ UNKNOWN S <br /> ►- DATE 019COVEAED NOW OWCOVERED ❑ INVENTORY CONTROL. ❑ aM1 MWACE M0=NIT0FW0 G ❑ NUISANCE coNORTRONs <br /> Z <br /> D ' Q TANK TEST TANK REMOVAL OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT Y) <br /> UNKNOWN Q REMOVE CONTENTS CLOSE TAW&REMOVE ❑REPAIR Prom <br /> HAS DISCHARGE BEEN STOPPED T / q <br /> C3 REPAIR TANK ❑C OSE TANK i FILL N PNCE ❑CHANCE PROCEDURE <br /> YES C] NO IF YES,DATE O I (� ( J C� ❑REPLACE TANK Q OTHER <br /> y� SOURCE OF DISCHARGECAUSES) <br /> S3 ❑ TANK LEAK UNKNOWN <br /> ❑ OVERFLL ❑ RUPTUREIFAILURE ❑ SPILL <br /> ❑.TIG LEAK ❑ OTHER ❑ CORROSION UNKNOWN Q OTHER <br /> W W CHECK ONE ONLY <br /> ❑ UNDETERMINE X901LONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY SEEN AFFECTED) <br /> CHECKONE ONLY <br /> NZ NO ACTION TAKEN Q aRE.wNARY SLTE ASSFSSfA@IT VIORKPLAN SUBMITTED ❑ PauuTRDN CHARACTERIZATION <br /> ?;P-! LEAK BENCONFIRMED D COMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY C3 POST CLEANUP MONITORING N PROGRESS <br /> 8 4D ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ C.EANIP UNDERWXY <br /> CHECK APPROPfSATE ACnON(S) ❑ EXCAVATE i D OP ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BID OEORAOATTON n <br /> pata•mc•o mma <br /> ❑ CAP SITE(CO) ❑ EXCAVATE E TREAT(ET) ❑ PUMP i TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RSI <br /> ❑ CONTAINMENT BARRIER CS) ❑ NO ACTION RECUI+R��pHA►� TREATMENT AT HOOKUP(HL4 ❑ VENT SOI,(V8) <br /> ❑ VACUUEX <br /> M TRACT NO OTHER 110y) qs:e ./ <br /> F <br /> Hac as 46" <br />