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00 • u.o�l- <br /> UNDERGROUND S A ORIZED RELEASE(LEAK)1 C TAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY USE OKY ;. <br /> REPORT BEEN FILED 7 .)HEREWCE3in THAT:HAVE DISTRIBUTE). INFORMATION ACCORDWG TO THE; <br /> ❑YES C]YES NO 61SM18i1T10N SHOWN ON THE INSTRUCTION SHEET.ON THE BACK PAGE OF THIS FORyI <br /> R/E�PORT DATE CASE s �� <br /> M <br /> p SCK <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> r L o rLl D LAIkCA� [7t�1) q�B 033 <br /> 00 <br /> w REPRESENTING ❑ OWNERIOPERATOR ED REGIONAL BOARD COMPANY OR <br /> �A}GENCY NAME <br /> LOCAL AGENCY ❑ OTHER a k V�jAeC9 L[[II� V('L <br /> ¢ <br /> AdDRESS <br /> _6_ r. 3 d cAJ eIry vzo <br /> W NAME CONTACTPERSON r PHONE <br /> i r l - \ s L[[ O�1 ❑ UNKNOWN <br /> ADDRESS {��,�, <br /> so L. STREET 1(�" 61 be t ar, � cm 15fosT�rE C� 5 �10 Z. <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> a ADDRESS <br /> 3 REIT S " D�a-I a ary S couwrrs� �z a <br /> H CROSS STREET . <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> P:LL, 5��, �c ro[�rvLec,, ( fL-f2 (�rl D u[Ica [ 1 y�Zo33 p <br /> wREGIONAL BOARD ! PHONE ` <br /> dp a tkkAtf 2WC GIN6 A�-7 ��3e�l p6) 5;5-3t1S- <br /> NAME OUANTITY LOST(GALLONS) <br /> LU <br /> LU <br /> - �� ❑ UNKNOWN <br /> u�o ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 14 04 D Y r ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Ij DI Yl UNKNOWN ❑REMOVE CONTENTS;!5GLOSE TANK A REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED t ❑REPAIR TANK ❑CLOSE TANK A FILL IN PLACE ❑CHANGE PROCEDURE <br /> G YES ❑ NO IF YES,DATE O� Y Y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGECAUSE(S) <br /> ❑ TANK LEAK UNKNOWN C-] OVERFILL ❑ RUPTURVFAILURE ❑ SPILL <br /> ❑ PIPING LEAK OTHER ❑ CORROSION UNKNOWN ❑ oTHER <br /> w Lu CHECK ONE ONLY <br /> ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z ❑ NO ACTION TAKEN ❑ PRELIM iNARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> y ❑ LEAK BEING CONFIRMED PRELIIMINARY SITE ASSESSMENT UNDERWAY ❑ POSTCLEANUP MONITORING IN PROGRESS <br /> ❑ REMEtXATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE O <br /> ACTINS) <br /> ❑ EXCAVATE S DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> 0 ❑ CAP SITZ:(CD) ❑ EXCAVATE 3 TREAT(E7) ❑ PUMP 3 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY{RS} <br /> a LU< ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQS�U�IIR�E�D,,(NA) ❑ TOO <br /> TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) <br /> In <br /> z <br /> W <br /> IS9C OS ISI <br />