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f-1 -77 <br /> ,c, <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 7 l HEREBY.CERTIF/THAT 1 HAVE DISTRIBUTED TH 19 INFORMATION,ACCORDING TO THE <br /> ❑ YES ❑ NO ❑ YES ❑ NO <br /> 'DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF.THIS <br /> REPORT DATE CASES <br /> 5 p 3 <br /> u u v SKiNE6. . DATE :I <br /> NAME OF INDWOUAL FILING REPORT PHONE SIGN TJRE: <br /> cn <br /> Lu REPRESENTING ❑ OWNERIOPERATOR Q REGIONAL BOARD COMPANY OR AGENCY NAMEcc 1 <br /> ri <br /> LOCAL AGENCY ❑ OTHER STC En vi Ii,-mi nlfeU ge'kl-M qDept rl7N.[. t <br /> a ADDRESS <br /> Stnc, � C� q5 Z� z- <br /> 37REET CITY' STATE ZIP <br /> w NAME �j -J}� 1 C' CONTACT PERSON f'C (7,M <br /> PHONE �7 <br /> Z I R� P. m V�1 �l•�C•-� ❑ UNKNOWN J�I•C.�i G Yl C ks � 1 Z )�37. V!7.3 <br /> y ADDRESS <br /> Cc PD 80X 2--7(P LS 015 3 0? <br /> $TR£ET CITY $TATS ZIP <br /> OPERATOR PHONE <br /> FACILITY NAME(IF APPLICABLE) <br /> mgtA EhtiN i�-s c ) <br /> a ADDRESS <br /> Hwy! Tf~ <br /> . �. X15 <br /> 0 7 1 �J� <br /> � STREET CITY COUNTY ZIP <br /> y CROSS ST�R�E.jErT! <br /> AW) <br /> 1 ✓, + <br /> 0 LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> U SSG 1 v;rnlnjcn- er& Wq ) 6 g <br /> w w REGIONAL BOARD PHONE <br /> CL <br /> W fI) NAME OUANTITY LOST(GALLONS) <br /> LU <br /> ❑ UNKNOWN <br /> m z !zJ W <br /> D <br /> UNKNOWN <br /> z DAT-DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MOVITORtNG NUISANCE CONDITIONS <br /> w /1 0 3 p <br /> w ul M� f n� a Y� Y ❑ TANK TEST ❑ TANK REMOVAL OTHER yy�1�UM 12ki r)A <br /> r <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> wM u o o Y y UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK S REMOVE E::]REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK 3 FILL IN PLACE ❑CHANGE PROCEDURE <br /> o ❑ YES ❑ NO IF YES,DATE ❑REPLACE TANK ❑ OTHER <br /> M u� n o r v <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> LL, <br /> Z)a ❑ TANK LEAK � UNKNOWN ❑ OVERFILL E] RUPTUREIFAILURE ❑ SPILL <br /> H O ❑ PIPiNGLEAK ❑ OTHER ❑ CORROSION I UNKNOWN Q OTHER <br /> N nw. CHECK ONE ONLY <br /> U UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK NE ONLY <br /> zV NO ACTION TAKEN ❑ PRELIM INARYSITE ASSESSMENT WORKPLANSUBM17TED POLLUTION CHARACTERIZATION <br /> y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> v ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> (SEE MCR FQi[flf'fAlil E] EXCAVATE 5 DISPOSE(ED) E::] REMOVE FREE PRODUCT(FP) E::] ENHANCED BIO OEGRADATION(IT) <br /> J <br /> Zg ❑ CAP SITE(CO)( Q EXCAVATES TREAT(ET) O PUMP 8 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Lu <br /> ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> ~ ��x <br /> w <br /> 8 <br /> . HSG cs Ia�F <br /> A. <br />