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UNDERGR ND STORAGE TANK UNAUTHO ZED RELEASE CONTA(LEAK)/ <br /> EMERGENCY ) MINATION SITE REPORT <br /> HAS STATE OFFICE OF EMERGENCY SERV ES F <br /> ❑ YES NO REPORT BEEN FILED? L AGENCY'USE ON <br /> ❑YES NO 1 EflEBY RTIFYTHAT.! AVE STRIBUTED THI NFORMATIp"ACCORDING TO THE <br /> PORT DATE ISTRIBU SHOWN 7 <br /> CASE s U SH ON THE$ACK PAGE OFTHIS FORM, <br /> y <br /> N F INDIVIDUAL FIL G REPORT N f <br /> m PP/JH/ONE SIGN qE DATE <br /> w pEPRESE NG <br /> cr ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPNY 0R AGENCY NAM <br /> aO OCAL AGENCY ❑ OTHER <br /> cc ADORES <br /> J NAM -. aco ��v <br /> z I: J / CONTACT PERSON A zip <br /> �� ❑ PHONE <br /> ti d ADDRESS vv( UNKNOWN ( �) 96 <br /> 31• <br /> FACILITY NAME(IF APPIK%ABLE) STREET '?4155(' <br /> STATE ,JCT/ <br /> OPERATOR <br /> O IP <br /> Z 0 T' �1 PHONE <br /> v ADORE ( ) <br /> Lu (z <br /> STREET 'G 9�.3 <br /> y CROSS STREET S� <br /> c <br /> ZIF <br /> FRALBOARD�AG � '&�DAGENCY NAMECONTACT PERSON <br /> PHONE <br /> CL <br /> PHONE <br /> ca <br /> O o NAME <br /> F J �SD�IJ QUANTITYLOST(GALLON <br /> m z (2) UNKNO <br /> I OATS DISCOVERED HOW DISCOVERED UNKNOWN <br /> 2 ❑ VENTORY CONTROL ❑ SUBSURFACE ONITORING ❑ NUISANCE CONDITIONS <br /> M ❑ TANK TANK REMOVAL ❑ OTHER <br /> m <br /> DATE DISCHA 'E BE N Y �T <br /> i <br /> METHOD USED TO STOP DISCHA E(CHECK ALL THAT APPLY) <br /> W D UNKNOWN ❑REMOVE CONTENTS CLOSE TANK 6 REMOVE REPAIR PIPING <br /> p HAS DIS ARGE BEEN STOPPED? ❑ CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE ` <br /> y REPAIR TANK ❑ <br /> p YES ❑ NO IF YES,DATE p 1 D y 2v F7REPLACE TANK ❑OTHER <br /> M <br /> wSOURCE OF DISCHARGE <br /> CAUSE(S) <br /> cr U <br /> j ❑ TANK LEAK UNKNOWN VR RE/FAILURE ❑ SPILL <br /> a ❑ OVERFILLU ❑ PIPING LEAK THER ❑ CORROSION NOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> Na <br /> O ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ <br /> POLLUTION CHARACTERIZATION <br /> S y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN <br /> ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> RP11%Ll ran CUA" ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> w o ❑ CAP SITE(CD) ❑ EXCAVATE a TREAT(ET) ❑ PUMP a TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> 2 a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(07) <br /> Z <br /> �Iul All J l� <br /> 4- -Iv°klein l <br /> U <br /> O <br /> MSC 05(8" <br />