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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)1 CONTAMI S 0 <br /> E RGENCY HAS STATE OFFICE OF EMERGENCY SERVICESR EQCAL AGENCY USE <br /> REPORT BEEN FILED? <br /> I <br /> YES 0 No Q YE s 1 FIEAEBY CERTIFYTHAT!HAVE o15TR18LfTED THIS If OR P.N`f f <br /> P <br /> REPORT DATE CASE s C BUFF SOWN ON THE wSTF[UcT) N SHEET ON 7HE BACK AGEI FORM <br /> r t> <br /> NAME 00 1NDtVPVAL FlUT4G R ORT PHONE SIGNATURE 'y <br /> m <br /> ,� REPRESENTING OWNEWOPERATOR Q REGIONAL BOARD COMPANY OR AGENCY AME <br /> g Q LOCAL AGENCY O ER Q <br /> C2 <br /> s ADDRESS <br /> o�o�-(off� <br /> > CITY ATE np- <br /> ui NAME /� CONTACT PERS PHONE n <br /> N ^�C c <br /> r <br /> CL y ADDRESS <br /> w <br /> .S w Gt S a-Lo U--e— <br /> STREET env STATE P <br /> FAC TTY NAME(1F APPLlCABLEy OPS R PHONE <br /> 0 3 _ a rc� . <br /> OADDRESS V V 1 / .f / e e V Ra� � k e I-odt � ���( C/�C �/h <br /> W STA EET TI'Y 1p <br /> ~ <br /> CROSSSTREET V ` <br /> m rJ/+[fJ1 <br /> ✓lam r <br /> z LOCAL AGEN AGENCY NAME CONTACT PERSON PHONE. <br /> z I LaCa �il� o ) 14 r6 <br /> M REGIONAs D PHON <br /> CL a ! ) <br /> CA (1) T + ,NAME ANTITY LOST(GALLONS) <br /> Lp0 <br /> Z J UNKNOWN <br /> m <br /> N Z <br /> O UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL SU FACE M ITORING NUISADP6W z NDITK)NS <br /> Lu <br /> I I `O Y Y THTANKTEST TANK REMOVAL R I <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> 4 ^ <br /> UNKNOWN �REMOVE CONTENTS Q CLOSE TANK&REMOVE: F-�REPAIR PIPING <br /> w n <br /> p HAS OISCHA <br /> STOPPED 9 a REPAIR TANK CLOSE TAN ILL IN CE CHANGE PROCEDURE <br /> y ES NO IF YES.DATE € i Q REPT AGE TANK ER ! �,` <br /> 0 M W O Y Y <br /> SOURCE OF DISCHARGE - US (S) <br /> Cc� � TANK LEAK 0 UNKNOWN OVERFILL RUPTUREIFAILURE a SPI j,,i ._m <br /> m F7 PIPING LEAK 0 OTHER CORROSION UNKNOWN + OTHER <br /> w a CHECK ONE ONLY <br /> U� F UNDETERMINED �' SOIL ONLY GROUNDWATER DRINKING WATER -(CHECK ONLY IF WATER WELTS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED a POLLUTION CHARACTERIZATION <br /> LEAK BEING CONFIRMED Q PRELI qY SlTE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> V N v <br /> REMEDIATION PLAN' SE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) cl <br /> CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACT1ON(S) Ej EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED 810 DEGRADATION(IT) <br /> (SEE OAM FOR OE1A&M <br /> a z 0 CAP SITE(CD) - Q EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT)ED REPLACE SUPPLY(RS) <br /> W a CONTAINMENT 13ARRIER(CB) Ej NO ACTION REQUIRED(N ) T TMENT A7 HOOKUP(HU) VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) OTHER(OT) S ILO 4 <br /> / <br /> S o YLe w�: JX0A rr a (s e2u Sr-e C-,*) ``�. <br /> opt8. <br /> s . <br /> r HSC 05(&M <br /> -14 <br /> rc Fr 1�` <br />