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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT SEEN FILED 7 <br /> ❑ YES NO ❑ YES NO 1 HEREBY,ClEfMFY THAr 1 HAVE DISTRIBUTE THIS INFORMATION ACCORDING TO TNF <br /> REPORTDATE 01ST UT SHOWN ON T TRUCTION SHEET ON THE BACK PAGE OF 15 F I <br /> CASE s <br /> Y <br /> NAME OF INDIVIDUAL FILING RE <br /> PHONE SIGNATU <br /> RE ELATING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD MPANYORAGENCYNAME� f <br /> cc <br /> O LOCAL AGENCY 011 OTHER <br /> ¢ ADORESS , 1 c[-'' T / K G W L <br /> 9TgEEf CfTY <br /> w 197-1 <br /> NAME CONTACT PERSON PHONE <br /> 1 fin` /y�y�y arnfp O <br /> lr"l V V V CA E�<.!/ UNKNOWN Na), <br /> J t✓� ! �`(O r� <br /> Qa¢ �" <br /> CL ADDRESS <br /> S AJ #ofks� <br /> $TATE 71. <br /> FA 5.15, <br /> NAME(IF APPLICABLE) OPERATOR PHONE \ <br /> 0rQ , r ,�� �h ��97�f�3 G oo <br /> Z <br /> 0 <br /> U ADDRESS <br /> P <br /> h CROSS STREET , toe <br /> 1 ca <br /> Sr <br /> z L LAGENC�� A NCY NAME NT CTPERSON (^ PHONE <br /> waawwm V VVV C� SS . h�l (O _3 r <br /> wV <br /> REGI AL 80]ApJ�1 /PHONE <br /> IL <br /> w (�) NAME QUANTITY LOST(GALLONS) <br /> 0 <br /> w <br /> Z o 0)) 1.-eNKNOWN <br /> co 7 <br /> N Z <br /> ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lu �J <br /> w MI �^IGI 00 oI r ❑ TANK TEST ❑ TANK REMOVAL ❑ OT-IER <br /> F <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE{CHECK ALL THAT APPLY) <br /> cc w M o Y UNKNOWN ❑REMOVE CONTENTS CLOSE TANK L REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPP.eD 7 ❑REPAIR TANK ❑CLOSE TANK 5 FILL IN PLACE ❑CHANGE PROCEDURE <br /> o <br /> 5?'YES ❑ NO IF YES.DATE D, o �r l7 Y ❑REPLACE TANK ❑OTHER A <br /> L <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> j ❑ TANK LEAK JNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> W O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION EEJ�UNKNOWN ❑ OTHER <br /> CL CHECK ONE ONLY <br /> v ❑ UNDETEAMINED SOIL ONLY ❑ GROUNDWATER Q DRINKING WATER -(CHECK ONLY IF WATER'WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY I <br /> o <br /> ❑ NO ACTION TAKEN Q�PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> S <br /> j y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY F7POST CLEANUP MONITORING IN PROGRESS <br /> o ❑ REMEDLATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> tseE eu ray oErnasi ❑ EXCAVATE b DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(M <br /> a <br /> w 0 ❑ CAP SITE(CD) E��EXCAVATE S TREAT(ET) ❑ PUMP 3 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Lu a ❑ CONTAINMENT BARRIER{CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) <br /> W �l �a �nr tee, �ICv Uri qyi ��y� y <br /> 0 <br /> NSC P5{9bq <br />