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UNDERGROUND STORAGE I UNAUTHORIZED RELEASE (LEAK)1 TAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES ''FOR COGAE.AGENCY:USE`QNIY <br /> YES NO REPORT BEEN FILED YES Q NO [Htkisi'CERTIFYTHAt I HAVE_DiSTR16(1TED THIS INFORMA7io6i`ACGORDryG TO THE <br /> DISTR IBUT SHOWNOWNadCT10N SHEET ON THE$ACK PAGE OF TH15 FORM <br /> REPORT DATE CASE R /f <br /> © M MI Y ;.S HED � - ��• �� <br /> k NAME OF INDIVIDUAL FILING REPORT PHONE �SIGNATUIR- <br /> REPRGSENTING <br /> 0 OWNER/OPERATOR E-1REGIONAL BOARD COMPANYOR AGENCY <br />- O LOCAL AGENCY a OTHER �,�� " P � �Td/� <br /> ow'. AD KESS "��II" <br /> An C4 <br /> STREET CITY STATE ZIP <br /> J NAME ,��� G �^ �n ry CONTACT PERSON PHONE <br /> z r- -<w&5io 1<,C6 /*�G.�" � UNKNOWN <br /> ti a ADDRESS �/� <br /> STREET CITY STATE iP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o E��� � n / 4 L1 <br /> ¢ ADDRESS <br /> w 47 d J�4 STREEI CrtY COUNTY ZIP <br /> m CROSS STREET <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z <br /> z� �v. Qr - <br /> w w REGIONAL BOARD PHONE <br /> J <br /> a a rr <br /> � 1 <br /> w (1) NAME QUANTITY LOST(GALLONS) <br /> v <br /> ULu <br /> NKNOWN <br /> m z (Z) <br /> 5- <br /> `f) UNKNOWN <br /> z DATE DISCOVERED ^7 X(J rrc HOW DISCOVERED O INVENTORY CONTROL O SUBSURFACE MONITORING Q NUISANCE CONDITIONS <br /> o I ..17- Fr o1 •Y r 11 TANK TEST 5d TANK REMOVAL OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> a <br /> < UNKNOWN REMOVE CONTENTS CLOSE TANK&REMOVE REPAIR PIPING <br /> Lu M M 0 O Y Y <br /> p HAS DISCHARGE BEEN STOPPED 7 REPAIR TANK CLOSE TANK&FILL IN PLACE 0 CHANGE PROCEDURE <br /> U <br /> 0 YES � NO IF YES,DATE REPLACE TANK OTHER <br /> O MI MI O O Y Y <br /> ED SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> 0,3 <br /> ❑ TANK LEAK UNKNOWN 0 OVERFILL Q RUPTURE/FAILURE SPELL <br /> �a <br /> c" 0 PIPING LEAK OTHER CORROSION UNKNOWN OTHER <br /> Lu w CHECK ONE ONLY <br /> w[L <br /> O UNDETERMINED SOIL ONLY a GROUNDWATER 0 DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z F--j NO ACTION TAKEN O PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> c r F--] LEAK BEING CONFIRMED F--J. PRELIMINARY SITE ASSESSMENT UNDERWAY F--j POST CLEANUP MONITORING IN PROGRESS <br /> 0 w E] REMEDIATION PLAN O CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) a CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) ED REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> J (wEB FO on ) <br /> Q o F-1 CAP SITE(CD) Q EXCAVATE&TREAT(ET) E] PUMP&TREAT GROUNDWATER(GT)O REPLACE SUPPLY(RS) <br /> Lu <br /> w¢ CONTAINMENT BARRIER(CB) � NO ACTION REQUIRED(NA} TREATMENT AT HOOKUP(HU) VENT SOIL{VS) <br /> rr <br /> El VACUUM EXTRACT(VE) F--j OTHER(OT) <br /> �p'�C- /,.p�+G y S"/� /�i�n�-r i�4; � �JS'yc�✓� T-rf ✓J/GO TF s'oi L Co i1/i ^iv JCt..�T <br /> Lury ffJS . tea*-mac)� <br /> U <br /> FILE COPY <br /> I <br />