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r 1� <br /> 95_ va s <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY-USE ONLY <br /> REPORT BEEN FILED ? <br /> VES NO r$YES ❑ NO 1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTEDTHIS INFORMATION ACCORDING TOTHE <br /> ❑ <br /> DISTRIBUTION SHOWN ON THE.INSTRUCTION.SHEET.ONTHE BACK.PAGE.OFTHIS FORM <br /> � <br /> REPORTDATE CASEA N "�yryMI 5r SIGNED DATE . <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATU E <br /> (A o9 ) 414 T/ 1C� srt <br /> R20RESENTING ❑ OWNE RATOR ❑ REGIONAL BOARD COMPANY OR AGEN/C�Y NAME V <br /> /`y'-S yy j <br /> a LOCAL AGENCY ❑ OTHER • Lp r ' ✓ `� [/ {�] <br /> ADDRESS <br /> P, d . erX 3 �l 3v �0 F pini ui �S`o c-fj�� 014 L 9v5A b! <br /> EET Cm S ATE ZIP <br /> mm <br /> CONTACT /PERSON y�+ �. /I PHONE r� <br /> z ¢ Fro ier Tres drf J-f✓\.❑ UNKNOWN UD �J � � I 1 + O r✓� (�� � � �Q/ Ute" ;� <br /> N ° ADDRESS 7 7 06 <br /> / <br /> REEr cm STATE ZIP <br /> FACILITY NAME (IF APPLICABLE) OPERATOR PHONE - <br /> r fr SM r i &K) to 6Q5i <br /> ADDRESS <br /> far c, h �( y S1�Tv ' orect y, 21853 <br /> STfE <br /> REET cm couN <br /> CROSS STREET <br /> LnGeL <br /> Q LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z Joe <br /> REGIONAL BOARD PHONE <br /> y (1) AlNAME QUANTITY LOST (GALLONS) <br /> aw GhS0 A,� 1 Y7 SZL 1� UNKNOWN <br /> y o> (2) <br /> ❑ UNKNOWN <br /> F- <br /> DATE DISCOVERED L_ HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> s b (�M 30 9r "JY ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> W DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> a <br /> M D UNKNOWN REMOVE CONTENTS IJP( CLOSE TANK & REMOVE ❑ REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED 4 r _ ❑ REPAIR TANK C] CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE <br /> o VES ❑ NO IF VES, DATE VM � j - `D / r JV ❑ REPLACE TANK ❑ OTHER <br /> URCE OF DISCHARGE CAUSES) <br /> a ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURHFAILURE ❑ SPILL <br /> 00 ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w CHECK ONE ONLY <br /> O � ❑ UNDETERMINED ❑ SOILONLY GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) I <br /> CHECKONEONLY <br /> ¢ Z <br /> F-1 ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION o ` <br /> rIEAK BEING CONFIRMED F-1PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> jI Oy //❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY UT` <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br /> APPROPRIATE <br /> oEA <br /> j a z ❑ CAP SITE (CD) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br /> 00 <br /> y w a ❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED INA) r, S S) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />,� ❑ VACUUM EXTRACT (VE) OTHER (On pA.E tL� e y YJ MU4a <br /> 71 <br /> ` 4 /mecy <br /> NSC M fb9% <br />