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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT # <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAi AGENCY USE pNLY <br /> REPORT BEEN FILED 7 <br /> ❑ YES NO O YES 2r44o 1}iEAE81 CEHi1FYTHA71 HAVE DI5TR18UTED THIS INFORMATIOtJ ACCORDING TOTHE <br /> REPORT DATE DISTRI8UTIQN SHOWN'D. THE INSTRUCTION SHEETAN THE BACK PAGE:OF THIS FORM <br /> CASE it - -;,.. - <br /> Vul I u� 3 DI r SIGHE6 7:1{TATE <br /> _ NAME OF INDIVIDUAL FILING REPORT PHONE 'k SIGNATURF- <br /> w REPRESENTING OWNERIOPERATOR Q REGIONAL BOARD COMPANY OR AGENCY NAME <br /> �OCALAGENCY ❑ OTHER � f]fi5` <br /> � D L(�tN1�.0 • 1 1 �'.C� <br /> m ADDRESS <br /> 3Dy •we-be r AvP ,t�k ,Th tird -F7 Da-- cStDGGi-D n CA 1?152Dz- <br /> STREET cm !i STATe <br /> J NAME ZIP <br /> CONTACTPERSON i <br /> ca <br /> Fn sOuzo— L-L--c— UNKNOWN } IJVGx��O C-(� 1Lam{I LS�S� <br /> 4 a ADDRESS <br /> Lu <br /> lD5 IN . ,vt- � � �2 +rGLC�f GA 9--537(, <br /> Crf] <br /> STREET STATE 1P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS f <br /> sw 2 I.v. C ? -�► <br /> REET C(TY ,. COUNTY ZIP <br /> y CROSS STREET <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON F <br /> z PHONE <br /> N <br /> nREGIONAL BOARD PHONE <br /> 4 C V ana Q t, X' C. / SS <br /> CL <br /> .I l 1 <br /> (t1 NAME <br /> W QUANTITY LOST(GALLONS) <br /> p <br /> c o [�J`UNKNOWN <br /> 0 <br /> j I 1 I A - TT ti_lJ` UNKNOWN <br /> D 1 (� <br /> z DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING O NUISANCE CONDITIONS J+ <br /> w l/>aI touI 1 p� fly y Q TANK TEST E/ TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> g + <br /> } uI Ul DI Y ,I lvi UNKNOWN Ej REMOVE CONTENTS LOSE TANK&REMOVE a REPAIR PIPING <br /> 4 <br /> w <br /> p HAS DISCHARGE BEEN STOPPED 7 REPAIR TANK , CLOSE TANK&FILL IN PLACE 0 CHANGE PROCEDURE <br /> � YES D NO IF YES,DATE {JuI Ip REPLACE TANK :; OTHER <br /> p SOURCE OF DISCHARGE CAUSES) F <br /> w <br /> CaF-1TANKLEAK UNKNOWN ElOVERFILL RUPTURE/FAILURE SPILL <br /> w D F PIPING LEAK 0 OTHER CORROSION ES�UNKNOWN OTHER <br /> Lu ww CHECK ONE ONLY i <br /> CL <br /> U UNDETERMINED SOIL ONLY E] GROUNDWATER 0 DRINKING WATER !(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY ) <br /> dNO ACTION TAKEN F--j PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTEO•' POLLUTION CHARACTERI7ATION <br /> y ❑ LEAK BEING CONFIRMED a PRELIM INARY SITE ASSESSMENT UNDERWAY 4 0 POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN O CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY Y <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) D REMOVE FREE PRODUCT(FP) E] ENHANCED BIODEGRADATION(IT) J1 <br /> <Z (SEE 5ACK FMMTALM <br /> 50 E-1 CAP SITE(CD) EXCAVATE&TREAT(ET) 0 PUMP&TREAT GROUNDWATER(GT)O REPLACE SUPPLY(RS) <br /> w a CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NyA)��jJ ED TREATMENT AT HOOKUP{HU) VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) OTHER(OT) r`4 �/► I n�/ S ti <br /> y rn <br /> u wkh�x sc�e, mess en,- ,CLQ 'be WAM <br /> Ct�ld e�•��- c� <br /> Yl .� o�F <br /> HSC as(&W <br /> i! <br />