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Lo '- <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FIOCAL`AGENCY USE QN�Y <br /> REPORT BEEN FILED 7 <br /> ❑YES NO ❑YES NO 11lERE81t CEF ?kiA 411�NfE DISTR DTH15 iNPC*iy M7 ACCOROuVG TdTHE:• <br /> REPORT DATE CASE DISit�[ITIOFpS�{OWI� E] STRUC. IDN:SHEET OM THrz$AICK.PAGE OFTHIS FORA4 <br /> a <br /> SIGNED <br /> NAME OF VA NVIDUAL FILING REPORT PHONE MSn" TURE <br /> � 3 <br /> 0 REPRESENTING ❑ OWNERIDPERATOR ❑ REGIONAL BOARD COMPA OR AGENCY NAME <br /> RLOCAL AGENCY ❑ OTHER Ptf� <br /> E ADDRESS <br /> 30 0-t, . eve.3`-z -t�� "I 7�l;— <br /> CITY STATE ZIP <br /> -i NAME CONTACT PERSON PHONE <br /> go <br /> Z Q wI��✓ ❑ UNKNOWN } <br /> a ADD Car 9�"�� 3 <br /> ul <br /> STREET CITY STATE p <br /> FACILITY NAME(IF APPLICABLE) TAY <br /> PERATOR PHONE <br /> F!bwl,#,w t5 �cr�v ,�Q[ Sio } q Lf y- 03 <br /> ADDRESS ( /+ ? Q <br /> JLf o E��d-bn srREEr S G17. �Lf A vl hCOUNTY I1 3 <br /> CROSS STREET f <br /> I--,' m .7 <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> zW t } Q <br /> w <br /> Lu REGIONAL BOARD PHONE <br /> W (t) NAME QUANTITY LOST(GALLONS) <br /> Q <br /> UNKNOWN <br /> UNKNOWN <br /> rD�A�TE DISCOVERED y HOW DISCOVERED ❑ INVENTORY CONTROL E3 SUBSURFACE MONITORING - ❑ NUISANCE CONDITIONS <br /> v 1 p o V v ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> Lu N <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK [::]CLOSE TANK d FILL IN PLACE ❑CHANGE PROCEDURE <br /> ® YES ❑ NO IF YES,DATE v v ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE($) <br /> WTANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> wCHECK ONE ONLY <br /> ❑ UNDETERMINED gQ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> NO <br /> N TAKEN <br /> ARY SITE ASSESSMENT woRKPLAN <br /> POLLUTION <br /> ❑ LEAK BTEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAYSUBMITTED POST CLEANUP MONITOR NGI IN PROGRESS <br /> Cf REMEDIATION PLAN ❑ CASE CLOSED(CLEIWUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTIONS) ❑ EXCAVATE i DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> gsrm pmoum e9 <br /> ❑ CAP SITE(CD) ❑ EXCAVATE i TREAT(ET) ❑ PUMP d TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) Yq%! <br />