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Ak- <br /> UNDERGR UND STORAGE TANK UNAUTHOR ED RELEASE (LEAK)/CONTAMINATION SITE REPORT f <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERV S rFOR LAGENCY USE ONLY=' <br /> REPORT BEEN FILED') ' <br /> ❑ YES NO ❑ YES NO IHE BYC PYTHAT:I HA IBUTEDTHISI CRMATION ACCORDING TOTHE <br /> REP0 1du I OWN ON T U N.THE BACK PAGE LS FOR <br /> ORT <br /> 0 -. <br /> ATE CASE I <br /> MI z 9 Sz <br /> N EOFWJDIVIDUALFILIN.PEPORT PHONE <br /> D/ IGNA RE <br /> w REPRE NTING ❑ OWNERIOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME�I.{, <br /> S LOCAL AGENCY ❑ OTHER i E// Illfff <br /> ¢ ADDRESS <br /> ,P5- /Vv rSah Jod4 c� ( � 9s0o <br /> J / E O no <br /> �p/ry/�ACTNPERSON PHONE <br /> i¢ UNKNOWN e / G(//) <br /> a a A <br /> FACT RY NAMgg(IF APPLICABLE) OPERATORABO ` / PHONE <br /> w A(OE� FM 4 RfW W-"�V AY,✓& SfOG —i-DYI S✓mm 95z(�9 <br /> y CROS TREET <br /> (eta Ia�n�n #ozzf <br /> O LOC GE AGENCY NAME CONTACTPERSON PHONE <br /> �w <br /> w= <br /> w w REGI AL BOARD PHONE <br /> m lIl NAME QUANTITY LOST(GALLO ) <br /> <w �SV( //CXR UNKNqNN <br /> j i i <br /> H UNKNOWN <br /> DATE DlSqOVERED HOW DISCOVERED ❑ ENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE(X)NDTDONS <br /> z �I <br /> w OM M mol o y y ❑ TANK TANK REMOVAL ❑ OTHER <br /> am DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHA E(CHECK ALL THAT APPLY) <br /> a <br /> UNKNOWN REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> iy M D Y <br /> yOp HAS DI HASRGE❑SEENOSTO Y ED S.GATE D f 9 y ❑REPLACE NK ❑CLOSEOTHETANK&FILL IN PLACE C:]CHANGE PROCEDURE <br /> J J <br /> o SOURCE OF DISCHARGE CAUSES) <br /> ¢ ❑ TANK LEAKUNKNOWN ❑ OVERFILL ❑ UPTURE/FAILURE ❑ SPILL <br /> H O ❑ PI LEAK ❑ OTHER E] CORROSION UNKNOWN ❑ OTHER <br /> mn CHECK NEONLY <br /> O UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER-(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) f <br /> CHECK ONE ONLY <br /> w� ❑ NOACTIONTAKEN Q PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERRATION <br /> =y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATES DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(M <br /> t�e.arw oeru81 <br /> a z <br /> wO F-1CAPSITE(CO) ❑ EXCAVATE&TREAT(En F7PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ca ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED INA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENTSOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> �Gvvrvt(lh/S/ QSS� w/ <br /> w <br /> qL -ex O{ fjimt�aJ�2ai1 Q �" �•� � <br />