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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGEN VICES FOR LOCAL AGENCTUSE ONLY <br /> REPORT BEEN FILED 7 1}fEREBYCERTIFYTHATI }EIIVEOISTRIBUTEDT}lIS1NFORh1AT10N{(CCDR�INGTOTHE <br /> YES NO YES Q. NO <br /> aIS7FIIBUTION SHOWN. .....i............ CTION SIiEET.ON THE.BACK A.AGE OF:THIS.FDRM::-, ... <br /> REPORT DATECASE t <br /> M MI oI I r :. DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> O� REPREINGQ OWNERAOPERATORQREGIONAL BOARD COMPANY OR AGENCY NAME <br /> 1 <br /> pLOCAL AGENCY OTHER . <br /> tr ADDRESS <br /> STREET vC" ZIP <br /> w NA/MEQ CONTACT PERSON PHONE } y r <br /> U) /�C/SDIJ �" '�y� C E]e-1UNKNOWN �~ S Ole <br /> a0.as ADDRESS <br /> y dL <br /> o f� <br /> ¢ a / o <br /> rrc� STREET �' CITY STATE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> a ADDRESS <br /> CRr COUNTY ZIP <br /> W <br /> ~ CROSS STREET <br /> N <br /> O CONTACT PERSON PHONE <br /> = LOCAL AGENCY AGENCY NAME"wU <br /> (Zap 41" X11,1 (�ka- ` ` il o- <br /> 7w- ) <br /> C REGIONAL BOARD PHONE <br /> CL <br /> rn (7) NAME QUANTITY LOST(GALLONS) <br /> Z y 5 O /r-t�— UNKNOWN <br /> N O (2} <br /> mz <br /> �z <br /> rn <br /> UNKNOWN , <br /> i DATE DISCOVERED D1 HOW DIS ED Q INVENTORY CONTROL SU FACE MONITORING n NUISANCE CONDITIONS <br /> MI MI oI o ( v TANK TEST TANK REMOVAL OTHER S f 74 <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> 4 <br /> UNKWN REMOVE CONTENTS CLOSE TANK E REMOVE E]REPAIR PIPING <br /> LLI <br /> HA�;r <br /> MGE BEEN STOPPED 7 REPAIR TANK 0 CLOSE TANK S FILL IN PLACE CHANGE PROCEDURE <br /> U' E] NO IFYES,DATE MI MI o v r E�]REPLACE TANK OTHER <br /> 0 <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> j a O TANK LEAK 2T UNKNOWN OVERFILL 0 RUP AILURE SPILL <br /> y r--� PIP IN OTHER CORROSION UNKNOWN OTHER <br /> a CHE05PKE ONLY <br /> cn <br /> vEn UNDETERMINED SOIL ONLY GROUNDWATER DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w NO ACTION TAKEN PRELIMINARY SRE ASSESSMENT WORKPLAN SUBMITTED I] POLLUTION CHARACTERIZATION <br /> c N F7 LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> rJ Q REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) a CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) 0 EXCAVATE h DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> a ss�eRc�con oErNsr <br /> W p r7 CAPS ITE(CD) 0 TT Q EXCAVATE i TREAT(EPUMPS TREAT GROUNDWATER(GT)0 REPLACE SUPPLY(RS) <br /> � <br /> 4 CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) t7 TREATMENT AT HOOKUP(HU) 0 VENT SOIL(VS) <br /> Q <br /> 1-1 <br /> VACUUM EXTRACT(M OTHER(01) r <br /> 7v <br /> 0 <br /> U <br /> HSC 45(81 <br /> rru <br />