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UNDERGROUND STORAGE TANK UNAUTHORIZED R LEAS�EAK)LAMINATION SITE REPO <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FQR LOCAL>;GENCY.USE ONE Y <br /> REPORT BEEN FILED 7 <br /> YES C NO [:]YES NO 1HEREBYCERiTFYTHAT.:NAVEDISTRIBUTEDTHISINFORMATIONACCOROINGTOT1iE <br /> :D15fR18UTK)NSHOWI'!ON THF IIJ57AUCTIDN SHEET ON 7HE BACK.PAGE OF3HIS FORM, <br /> REPORT DATE CASE <br /> paTE. <br /> NAME OF INDIVIDUAL FI ING REPORT PHONE SIGNATURE <br /> ca �- o r I o Pei 4(.4-3`tyl <br /> REPRESENiI ❑ OW A!l?PERATOR ❑ REGIONAL BOARD SMPANY an OR Q�� �4 LJ„AGENCY NAME <br /> I _- � b i I G <br /> aLOCAL AGENCY ❑ OTHER a 1 r. TVJ► Q14t, D r JI <br /> U.1 a DRESS Z <br /> STREET CRY STATE ZtP <br /> w NAMEPCONTACTPERSON PHONE <br /> Z ':w GAS 5 -9-rM a n �rn 1 [] UNKNOWN a� <br /> Ocr <br /> aADDRESS � C.♦r � <br /> WT <br /> 1313 <br /> 3TFIEET CRY. STAVE P <br /> FACILITY NAME(IF APPLICABLE) r OPERATOR PHONE 1 <br /> vP c� I _ <br /> ADDRESS �" � r-- I <br /> o <br /> w STREET Cm couHrr <br /> CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z <br /> W 5�" 1oa q� x n Ca u U c rt7� Irye7� r( u g4ol <br /> wU U <br /> CL s REGK) A a PHONE <br /> °L i l <br /> m (S) 11 NAME QUANTITY LOST(GALLONS) <br /> Z w n�, ❑ UNKNOWN <br /> 03 m I <br /> U)— <br /> UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORINGrNUI/S�AN}CCE,CONL)RK)NS <br /> IIIE::]O I r TANK VEST ❑ TANK REMOVAL OTHER 1f>rz ►l M t ]S ry( <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> 4 <br /> 4 UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> w w <br /> aI r <br /> l 1 <br /> ? HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> 0 rrr--- Ih <br /> YES ❑ NO IF YES,DATE I ❑REPLACE TANK ❑ OTHER <br /> M Oil yl r <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> en <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREUFAILURE ❑ SPILL <br /> PIPING LEAK ❑ OTHER ❑ CORROSION {UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> HECK ONE ONLY <br /> Lu <br /> ❑ NO ACTION TAKEN PRELiMINARYSI7E ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> U <br /> w ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 810 DEGRADATION(IT) <br /> J ISM DAM FCR CETALM .. <br /> aZ <br /> I CAP SITE(CD) ❑ ExCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> LU <br /> Lu <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REOUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> 6 O <br /> VACUUM EXTRACT(VE) ❑ OTHER(01) <br /> 1 <br /> z f <br /> w I <br /> O <br /> U <br /> r HSCaSf 9% <br />