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Rqp <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL-AGENCY USE ONLY: <br /> YES. NO REPORT BEEN FILED? YES Q NO It{ REBY.CEFMFYTHATI HAVEDISTRIBIlTED.THI5INFOFiMATICdJACCORDINGTOTHE <br /> l31STR18UTION SHOWN ON.THE INSMCFIDN SKEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATECASE Sr <br /> UMI MI/ -7 q SIGNED <br /> > NAME OF INDIVIDUAL FILING REPORT PHONE � � � � SIGNATURE <br /> — <br /> o REPRESEN OWNERrOPERATOR REGIONAL BOARD COMPANY OR AGENCY NAME <br /> cc LOCAL AGENCY OTHER <br /> ¢ ADDRESS w .y <br /> Ys ice . �4Lv�� �. �_ - - <br /> ETRE CITY STATE zip ! <br /> w NAME CONTACT PERSON PHONE <br /> 12 <br /> J rCy <br /> J <br /> z 4 C �. Q UNKNOWN Ly Vvt{ yA <br /> Da a ADDRESS I <br /> S <br /> `tas ti :G-fc <br /> CS L <br /> STREET crry STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR 1� IP.HHONE l <br /> z i'tG C.C]. Cir C� 1 1G ) *_L � _) <br /> 6 <br /> � _ 3 <br /> aADDRESS <br /> 1-4— v[ r'C �v`� '•'^� cr `( � I�\ Y414� ► <br /> sY STREET r CITY COuHTV P <br /> ~ CROSS STREET <br /> c4 [ L Yvt ( ! <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> 2 N r <br /> rl / <br /> w <br /> wu <br /> w REGIONAL BOARD PHONE <br /> E* NAME OUANTITY LOST(GALLONS) <br /> LU <br /> U Lu UN t <br /> Z J / <br /> O> (2) <br /> m Z <br /> � UNKNOWN <br /> a GATE DISCOVERED HOW D S RED ENTORY CONTROL SUBSURFACE MONITORING E:] NUISANCE CONDITIONS <br /> LLJ <br /> w MI G�nI �o G Y Y TANK TEST TANK REMOVAL Q OTHER <br /> a <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(C ALL THAT APPLY) <br /> a <br /> ,y M M o o v <br /> UNKNOWN REMOVE CONTENTS OSE TANK S REMOVE REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED? REPAIR TANK CLOSE TANK&FILL IN PLACE 0 CHANGE PROCEDURE \\^\ ` <br /> 'A V r <br /> 0 YES Q NO IF YES.DATE j j u r v REPLACE TANK OTHER <br /> SOURC OF kARGE CAUSE(S) <br /> w <br /> ¢ TANK LEAK UNKNOWN OVERFILL RUPTURE/FAILURE SPILL <br /> v PIPING LEAK Q OTHER CORROSION KNOWN OTHER <br /> y aw. CHECK ONLY <br /> UNDETERMINED SOIL ONLY GROUNDWATER DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED} <br /> CHECK ONE ONLY <br /> z NO ACTION TAKEN F7 PRELIM INARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> cc <br /> r LEAK BEING CONFIRMED a PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> m 0 REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ED EXCAVATE 5 DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED 1310 DEGRADATION(IT) <br /> IEEE WX FOR WTALM <br /> a Z ❑ CAP SITE(CD) Q EXCAVATE S TREAT(ET) PUMP E TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) I <br /> Lu a CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) � TREATMENT A7 HOOKUP{FiU) VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) OTHER(OT) <br /> / 4. <br /> ry- �lirr i'� :tic y S //-r' GE S-s�s s w/._. L;�t!1 ✓ 4.f <br /> tu <br /> �ti�; tit;,c Co,,. <br /> ~ HSG 05(aW <br />