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i <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)!CONTAMINATION SITE REPORT <br /> a <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES pR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 YES ❑ NO j}lERE9Y C <br /> YES NO ERT1FYTkiA7 THAT THIS INFORMATIONINFORMATIONACCORDING TO THE <br /> ❑ <br /> .pISTR18UT3CN SHOWN ON T)i�.INSTAUCTII?N SHEET ON THE BACK PAGE OF THIS FDRN! <br /> REPORT DATE CASE* <br /> b� 7�I l/d �Q L/ f r SIGHE6 DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> co br' S 1 g <br /> wREPRESENTING ❑ OWNFR; PERATOR ❑ REGIONAL HOARD COMPANY OR AGENCY NAME <br /> pLOCALAGENCY ❑ OTHER <br /> Amo �-�- 3���-��-' ��"o cl�f�rn1 G <br /> STREET GITr STATE ZIP <br /> ti <br /> NAME . C �f{� �+y� CONTACT RSON <br /> zr— �L,! `���� • {�V T/ ❑ UNKNOWNS w <br /> a d ADDR S <br /> sI� - G C1.5 dig <br /> STREET Gm' STATE - IP <br /> FACILITY NAME(IF APPLICABLE) PHONE <br /> f OPERATOR <br /> C SaG -- {aa97 3 _ <br /> ADDRESS i �aa& <br /> w COUNTYZIP <br /> ~N CROSS STREET ')4 <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w S , Co l 5 f f .D ni � ,�a, <br /> w w REGIONAL BOARD uPHONE <br /> w (1) NA QUANTITY LOST(GALLONSJ <br /> v �� � °� .11 UNKNOWN <br /> Lu <br /> z <br /> 6 J <br /> (p c E� <br /> I-0- <br /> (z) <br /> N_ <br /> ❑ UNKNOWN <br /> z PATE OISCAIVERED +] HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONI ORING ❑ NUISANCE CONDITIONS <br /> Lu <br /> Luu� u1 D.1 o 1 r ❑ TANK TEST ❑ TANK REMOVAL OTHER r <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT A PLY) <br /> m <br /> a <br /> ccUNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> wDI yl r <br /> HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> O YES ❑ NO IF YES,DATE M MI .1 <br /> yj v ❑REPLACE TANK ❑ OTHER <br /> OURCE OF DISCHARGE CAUSE(S) <br /> Lu <br /> i o a ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILLa ❑ RUPTURE/FAILURE SPILL <br /> y v PIPING LEAK ❑ OTHER ❑ CORROSION X UNKNOWN ❑ OTHER <br /> N w CHECK ONE ONLY <br /> U UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> k w NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> I <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> f <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED WO DEGRADATION(IT) <br /> J <br /> (SM& CK KR MTAXSI <br /> Ei LU p❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> a <br /> ❑ CONTAINMENT BARRIER(CB) E] NO ACTJON REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) E] VENT SOIL(V5) <br /> w <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> E r <br /> U <br /> I r <br /> HSC 05 4&941 <br />