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UNDERGR ND STORAGE TANK UNAUTHO ZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERV ESF C'AGENCY USE ON <br /> REPORT BEEN FILED 1 <br /> YES NO Ey NO <br /> YES 1 EREBY_ RTIFYTHAT] AVE STRIBUTEDTHI HE NFORMATION ACCORDING TO T <br /> ❑ ❑ <br /> ISTRIBU SHOWN T U ON THE BACK PAGE OF THIS FORM <br /> R PORT DATE CASE 1 <br /> V rAI I [ v N OATE <br /> NAME F INDIVIOUAL FFG REPORT PHONE SIGN RE <br /> m <br /> V/OS T '�ol}q(�8'l� 35 <br /> Lu REPRESE NG a OWNERtOPERATOR ❑ REGIONAL BOARD CO AGE Y N <br /> Scc <br /> [ZKOCAL AGENCY OTHER 5 <br /> cc <br /> ADORES ,y <br /> STATE ` �ZIP <br /> J NAM le� J ,y CONTACTPERSON PHONE <br /> co <br /> Z Q !LC/( �� �[�/ ❑ UNKNOWN <br /> a¢ ADDR0 CLESS �j p <br /> cr <br /> STREET STATE IP <br /> FACILITY NAME(IF APPLICABLE) �r W OPERATOR PHONE <br /> 0 ( } <br /> a <br /> ADDRE <br /> 57 J- <br /> L u COUNTY <br /> rn CROSS STREET y <br /> Z L AGFvN� ' AGENCY NAME CONTACT PERSON PHONE <br /> W_ } <br /> Z <br /> U <br /> L4 w REGtpNAL BOARD ^� PHONE <br /> NAME <br /> UA p QUANTITY LOST(GALLON <br /> > <br /> 0)o <br /> UNKNO <br /> N <br /> j 2 <br /> 'D <br /> N {� <br /> UNKNOWN u\` <br /> �- DATE DISCOVERED HOW DISCOVERED + <br /> w I ❑ VENTORY CONTROL ❑ SUBSURFACE ONITORING ❑ NUISANCE CONDITIONS <br /> w �rM M J ?/ ❑ TANK TANK REMOVAL ❑ OTHER [ <br /> � � r r <br /> a DATE DISCHA GE BE&N METHOD USED TO STOP DISCHA E(CHECK ALL THAT APPLY) <br /> w D Y UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE REPAIR PIPING <br /> pHAS DIS ARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE ` <br /> -p YES ❑ NO IF YES,DATE V l o r Zr ❑REPLACE TANK ❑OTHER <br /> U SOURCE OF DISCHARGE <br /> CAUSE(S) <br /> w <br /> a ❑ TANK LEAK EV/UNKNOWN ❑ OVERFILL <br /> &R RE/FAILURE ❑ SPILL <br /> U ❑ PIPING LEAK [;-OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> H ww CHECK ONE ONLY <br /> CL <br /> v ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ~rn NO ACTION TAKEN <br /> LL, ❑ ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> j y ❑ LEAK BEING CONFIRMED 0 PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACT10N(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(In <br /> I�mac fan OETA4E( <br /> p p ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w� <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> 00 10 1 <br /> cnAi <br /> i *-Q- <br /> 0 <br /> to <br /> NSC 05(&gq <br />