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1- a <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)!CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY;rl0 <br /> s FOR,LOCAL'AGENCT: SE ONLY <br /> ❑ YES /No <br /> REPORT BEEN FILED 7 YES. (HE ER7iFYTHAT.1']HAVE 0163 1R 6'T'ED'T INFORMATION"ACCORDING TO THE <br /> DIS BUT SHOWN CWTHE IN UCT EET ON E PAGE OF> HIS FOR <br /> A OR ATE CAS€� +� <br /> } <br /> SMI S� 9 I SIGN PATE <br /> N41u1OF INDIYMALFI�N�R��� PHONE SIGNATU E <br /> 71ze-6V <br /> REPAESE INC ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMP Y DR AGENCY NAME <br /> 0 IrLOCAL AGENCY ❑ OTHER rr <br /> o�'c ADD E $ <br /> -�� Al, � C4 <br /> I STaEET Cm f STATE ZIP <br /> w NA ri" �QNNACT PEq.SOp ! PHONE C� <br /> oLV I I l< 14- ❑ UNKNOWN ax (J� �/�I i!I "v( fes" / ! `7/ /4q <br /> Ix <br /> 64 <br /> a <br /> y ADD SS O 6Vx <br /> TM <br /> L � ! II <br /> 2 <br /> �. STREET STATE <br /> IP <br /> FACSLf� (IFAPPhAE) OPERATOR Ii I' PHONE <br /> a <br /> a ADORES <br /> S N CROSS S//;;REF�T d <br /> W��C2 I <br /> ZIP <br /> I ;'1 <br /> LOCA GENCY AGENCY NAME CONTACT PERSON PHONE <br /> z y Eft L) I <br /> z <br /> REGIONAL BOARD i II PHONE <br /> y 11) NAME I QUANTITY LOST(GALU <br /> LLO <br /> Qo IUNKNOWN 1 <br />` m z (2) <br /> UNKNOWN <br /> ? RATE DI YERED OW DISCOVEREDLu ❑ NVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w M� of Ry y ❑ TANK TEST TANK REMOVAL ❑! OTHER <br /> i� <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP IMSCHA (CHECK ALL THAT APPLY) <br /> 4 I <br /> w n Y y UNKNOWN ❑REMOVE CONTENTS CLOSE�1 TANK d REMOVE ❑REPAIR PIPING <br /> HAS DI }LARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK rG FILL IN PLACE ❑CHANGE PROCEDURE <br /> YES ❑ NO lF YES,DATEMI o I yl y E:]REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE 01 CAUSE(S) <br /> w <br /> o V ❑ TANK LEAK UNKNOWN ❑ OVEAFILL ❑ PTUR EIFAILURE ❑ SPILL <br /> ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> I. <br /> u a CHECK ONE ONLY `r <br /> O ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK O�LY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED k ! POLLUTION CHARACTERIZATION <br /> LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY IF POST CLEANUP MONITORING IN PROGRESS <br /> to <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) jI CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATES DISPOSE(ED) ❑ REMOVE FREE PROD'CT(FP) ❑ ENHANCED BID DEGRADATION(IT) <br /> 15M W4K FCR MTAtM - <br /> 0 0 ❑ CAP SITE(CD) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP aE TREAT GROUNDWATER{GT)❑ REPLACE SUPPLY(RS) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> cc <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) I 14 ¢ <br /> w <br /> 0 v <br /> HSC 0511 <br />