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I <br /> UNDERGR UND STORAGE TANK UNAUTHOR ZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> I EMERGENCYHAS STATE OFFICE OF EMERGENCY SERV s FOR LOCAL AGENCY USE ONLY <br /> 1 REPORT BEEN FILED Z <br /> r ❑ ves No ❑ YES NO ) E CERi1FYTHATI_HAVE DISTRIBUTED IS INFpgMATION ACCORDING TOTHE <br />.� ISTRIION SHOWN ON:THEW Uf' <br /> REPORT{�ACASES <br /> � N EO E AGE <br /> OM VMI O I , FTHISF M - <br /> E <br /> NAM51QJ INDIVIDUAL FILL REPORT PHONE LGN RE <br /> m CLnl7 i;Dle�-� on '��8�3y <br /> 2 <br /> REPRESSNG ❑ OWNERIOPERATOR I❑ REGIONAL BOARD CONY <br /> 9RAGENCYNAME V, <br /> g LOCAL AGENCY ❑ OTHER <br /> ¢ AD SS <br /> S l� �ar�E�oa crr,.� stocan C � g5Z0 <br /> w NAME //'J y� ^ CO TT,A�CCT PERSON L PHONE <br /> �f y/ R <br /> i¢ �IKhorn i�Q�/l � ❑ UNKNOWN <br /> !/ `�l' <br /> wa ADDRESS <br /> jpsp �1Khorrj 7�y►�e- S GS <br /> BEET cm §TAM <br /> FACILITY NAME(IF APPLICABLE) PERAT R PHONE <br /> lChbr Cdurrl,- C�h ess 12oy, y -8f�96 <br /> a ADDRESS <br /> w �05b �lkho n�� �rN�2- .���f-zy! S � • 95Z49 , <br /> y CRS STREET / <br /> l� QCcG'I ( <br /> O LOC GE CV I'DAGENCTNAME CONTACT PERSON PHONE <br /> 1-w <br /> ws <br /> wa, REGIf7NAUB00 ,^ PHONE <br /> � r <br /> 0 (T) NAME QUANTITY LOST(GAUL ) <br /> Qwa 5o�in� <br /> J UNKNOWN <br /> mi m i <br /> y ❑ UNKNOWN <br /> DATEI DWOVERED HOW DISCOVERED ❑ ENTORY CONTROL ❑ UBSURFACE MONITORING ❑/ NUISANCE CONDITIONS <br /> DMI MI 0.17-.19,1j v ❑ TANK TES TANK REMOVAL OTHER ��h /QeS U ITS Sol�SQrnPlP <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARG (CHECK ALL THAT APPLY) <br /> UNKNOWN ❑REMOVE CONTENTS LOSE TANK&REMOVE ❑REPAIR PIPING <br /> w M M 0 Y <br /> o HAS DIS AGE BEEN STOPPED Z ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> a VES ❑ NO IF YES,DATE 0.' Zp I r Y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ?a ❑ TANK LEAK UNKNOWN E:] OVERFILL ❑ RUPTURErFAILURE ❑ SPILL <br /> m O ❑ PIPINGLEAK ❑ OTHER ❑ CORROSION 1NKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> O� ❑ UNDETERMINED We SOIL ONLY ❑ GROUNDWATER ❑ DRINKINGWATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wp ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> �w ❑ LEAK BEING CONFIRMED ❑ PR2LlMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS n <br /> o ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY y <br /> CHECK APPROPRIATE ACTION(S) C( EXCAVATE d DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> Isff vu wncerAUT <br /> < ❑ CAP SITE(CO) ❑ EXCAVATE&TREAT(ET) ❑ PUMP d TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w a ❑ CONTAINMENT BARRIER(CS) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ¢ p <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> yrWl�l' S i Cc �eflvcm 6v) �c JA ltLi <br /> w �X L� ( CGY1�GvvYl l n a{ wort <br /> a5 Y2,--�LG uciLe 7 " 6 <br /> U <br /> ULCI�GY� Q Z <br /> HSC 0 IASN <br />