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UNDERGROUND STORAGE1 WANK UNAUTHORIZED RELEASE(LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCA °AGENCY:USE:ONLY. . <br /> REPORT BEEN FILED?YES NO YES NO I HEREBY.CERT1FYTHAT 1:HAVE DISTRIBUTED THIS INFORMAT)ON.A000RDING TO THE <br /> Q Q <br /> DISTRI8UTIO4SHOWNONTHE" UCTIONSHEETONTHE BACK.PAGEOFTHIS <br /> FORM <br /> REPORT DATE CASES ' <br /> bM gM, o a 9 J ``� <br /> 'SIGN <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATUR <br /> m <br /> w REPRESENTING a OWNERIO OR 0 REGIONAL BOARD I COMPANY OR AGENCY NAME <br /> ui <br /> LOCAL AGcr ENCY Q OTHER <br /> ui <br /> cc A ORESo 3 g/ -S740 c fry Cf.�- <br /> �! STREET cm STATE ZIP <br /> III w NAME CONTACT PERSON PHONEIK <br /> t <br /> I cn <br /> Z� CA DzmAuj- 1 <br /> a UNKNOWN / <br /> O m �+ I <br /> COL Q ADDRESS 9 J���Z <br /> m o <br /> Lu <br /> 0= v/�� -� cRY 57ATE P <br /> STREET <br /> FACILITY NAME(IF APPLICABLE) OPERATOR 46 <br /> �E 11) <br /> q'14? 7�z ; <br /> 0 <br /> UADDRESSSTRE <br /> Lu P <br /> N CROSS STREET r <br /> EVI <br /> LOOCCA�L`AGGEENCY j.A.GE(NCCYrN`A7ME CONTACT PERSON PHONE <br /> w w REGIONAL BOAR PHONE <br /> a. <br /> m NAME OUANTITY LOST(GALLONS) <br /> w <br /> 0 w UNKNOWN <br /> Z <br /> Q J <br /> m O �) <br /> N z a UNKNOWN <br /> D DI VERED ^ p HOW DISCOVERED a INVENTORY CONTROL SUBSURFACE MONITORING Q NUISANCE CONDITIONS <br /> z <br /> L o TANK TEST TAN <br /> j mi 00 d K REMOVAL OTHER <br /> _ V v r <br /> Q DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) r <br /> m <br /> UNKNOWN REMOVE CONTENTS CLOSE TANK E REMOVEa REPAIR PIPING <br /> w u 01 r ` <br /> HAS DISCHARGE BEEN STOPPED? REPAIR TANK O CLOSE TANK S FILL W PLACE a CHANGE PROCEDURE <br /> o YES NO IF YES.DATE M v v REPLACE TANK Q OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> -B w <br /> j TANK LEAKUNKNOWN Q OVERFILL RUPTURE/FAILURE a SPILL <br /> v PIPING LEAK a OTHER a CORROSION Q UNKNOWN a OTHER <br /> W w CHECK ONE ONLY <br /> H a <br /> U UNDETERMINED SOIL ONLY GROUNDWATER [:] DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Z y NO ACTION TAKEN 0 PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED Q POLLUTION CHARACTERIZATION T <br /> w t.y• <br /> a (LEAK BEING CONFIRMED Q PRELIMINARY SITE ASSESSMENT UNDERWAYcr POST CLEANUP MONITORING IN PROGRESS <br /> U rn l❑'` REMEDIATK)N PIAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) E] CLEANUP UNDERWAY 4 <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE 6 DISPOSE(ED) a REMOVE FREE PRODUCT(FP) ENHANCED BIODEGRADATION(IT) <br /> t9ma ac Fm oeuam <br /> Q z � CAP SITE(CD) EXCAVATE&TREAT(ET) Q PUMP&TREAT GROUNDWATER(GT)80 <br /> REPLACE SUPPLY(RS) <br /> w a CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) OTHER(OT) <br /> caI- <br /> Z <br /> w <br /> o . <br /> U ' <br /> 4 SI HSC o5(0'90) <br /> � � s <br />