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( <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT <br /> EMERGENCY , HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAVAGENCY USE ONLY <br />'I REPORT BEEN FILED ? I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE: <br /> ❑ YES NO ❑ VES ❑ NO <br /> ,DISTRIBUTION SHOWN QV THE INSTRUCTION SHEET ON THE BACK PAGE OFTHIS FORM <br /> RJJERT�DATE CASE <br /> MI mi <-J O sIGxFD DATE .: <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> 13 6 <br /> w OWNENO TOR ❑ REGIONAL BOARD COMPANY OR AGE CY NAME <br /> REPRESENTING ❑ <br /> p LOCAL AGENCY ❑ , bth7 <br /> OTHER (,, _ /( {Sy, 4/' <br /> o � / <br /> opEss / Ql /� Ie , '1LL/ <br /> ufj <br /> 3a <br /> STREET CRY STATE ZIP <br /> NAME,. CONTACT PERSON C PHONE j C J lrn <br /> w ��U C�' �� F� IY S 3 ❑ UNKNOWN <br /> a a <br /> ADOREs �" <br /> �0 25 .5 oZ GYJC% G I,DC' f'� GSC` K� gc5AG <br /> STREET CRY STATE 21P <br /> FACILITY NAME BF APPLICABLE) OPERATOR _ PHONE <br /> B GaAoc� c �.h c/z4 d,r) <br /> ADD7RESS H �Ll) <br /> OJ / / ) STREET CRY , , CORHTY ZIP <br /> CROSS STREET <br /> N <br /> PCL,(% k ; <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> � U <br /> w REG NAL BOAPO PHONE ems, <br /> 6) <br /> NAME l ) 1 <br /> ) I • NAME QUANTITY LOST (GALLONS) (� <br /> z w UNKNOWN <br /> / �_ \/ — >DI Y ) ll . O <br /> 00 <br /> < > <br /> A <br /> oo (21 <br /> UNKNOWN <br /> DATE DISCOVERED �)!J i HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> arA1 5M ' 01 oI `� v 1 v ❑ TANK TEST TANK REMOVAL <br /> 0E] OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> UNKNOWN IhLREMOVE CONTENTS I/NI CLOSE TANK & REMOVE ❑ REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED 7 yl v ///❑j REPAIR TANK /❑ CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE <br /> a YES ❑ NO IF YES, DATEMI o v v ❑ REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE M CAUSE'S) <br /> w ❑ TANKLEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> w O F-1 PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w CHECK ONE ONLY <br /> U ❑ UNDETERMINED SOIL ONLY EDGROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CH* EC IK ONE ONLY <br /> ww gM NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENTWORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ¢ � ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O m ❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARI) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br /> 4sFE SracieSOETlusl <br /> 0 0 ❑ CAP SITE (CD) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br /> wa F-] CONTAINMENTBARRIER ICE) ❑ NO ACTION REQUIRED{NNA) ❑ TREATMENT <br /> yA,T,THHO�O�K�UP((HU) ❑ VENT SOIL (VS) <br /> F-1VACUUMEXTRACT (VE) OTHER (OT) Si / e r,( ` e. <br /> �L �y��Z>G�� �c�'-2i �' �> �'� ✓I� ��Z� <br /> M <br /> `�ft) �� CiGLQ TGt 2i�'1 C f [C /c <br /> O lam / L�Z�J'7i�iG '�-E GT/� HSCc 4"O) <br />