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1 <br /> - - ?G- U1.5UNDERGROUND STORAG9NK UNAUTHORIZED RELEASE(LEAK) ONTAMINATION SITE REPORT <br /> EMERGENCY <br /> HAS STATE BEEN <br /> RI OF EMERGENCY SERV S !'FOR OCAI`AGFrEL'Y:USE ONE Y :> <br /> R£POa7BEENFILE07 tHERESYCERTIFYTHAT> HAVE DE BUTED-i iIBINFCRMA-nCUACCOROENGTOTHar <br /> I YES NO YES NO <br /> BUTK)N SHOWN. THF WSTAUCTIDN SHED 6N 7HE BACK PAGE OF:T)!t5 FORM_ <br /> REPORT DATE CASE D rE .'`...... �••' <br /> slcrl <br /> Iu ::: :..:..- <br /> TE <br /> NAME OF INDIVIDUAL ING REPORT PHO SIGNATURE <br /> } ! i -� <br /> [AE�PLOCAL <br /> RESNG OWIIERfOPERATOR Q REGIONAL BOARD PONY OR AGE NAIJE AGENCY Q OTHER �--/J`^�1 1 Y� Imo+-2�..�1�"a� A-al/(`" <br /> 2 I ADDRESS <br /> 4,6 UT SrA7E na 1 <br /> Lu NA E CONTACTPERSON PHONE <br /> J rr <br /> 1,gl a. <br /> LQ UNKNOWN l } <br /> a< ADDRESS <br /> Na <br /> W ZO 7 <br /> STRpET ClIY 5'CATE ZIP <br /> FAC ITY NAME(IF APPLICABLE) OPERATOR - PHONE <br /> c ADDRESS ; <br /> U <br /> Z srEr G-L.i <br /> cmr cou <br /> y <br /> CRdSS STRUT <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w l.A W 7 c.L�.&j <br /> ui U <br /> w w REGIONAL BOARD PHONE <br /> H (1) NAME QUANTITY LOST;�NwUNKNOVYN <br /> J <br /> H <br /> c <br /> yQ UNKNOWN <br /> D�A/T�JE�DISCOVERED HOW OLSCOVERED ❑ IHV ORY CONTROL Q SUBSURFACE MONITORING Q NUISANC'c CONDITIONS <br /> W -^'7W�!MIO D R/ Y <br /> � TANK TEST TANK REMOVAL OTHER <br /> 4 <br /> � <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP p[SCHARPE(CHECK ALL THAT APPLY) <br /> / <br /> u o v <br /> UNKNOWN Q REMOVE CONTENTS CECLOSETANK&REMOVE Q REPAIR PIPING <br /> Lu <br /> HAS DIS RGE BEEN STOPPED? Q REPAIR TANK Q CLOSE TANK S FILL IN PLACE Q CHANGE PROCEDURE <br /> NO IF YES,DATE u 0 0 r ❑REPLACE TANK Q OTHER <br /> 0 <br /> SOURCE OF DISCHARGE (S) <br /> aQ TANK LEAK UNKNOWN Q OVERFILL Q RUUP�TUREIFAILURE Q SPILL <br /> y U Q PIPING LEAK Q OTHER - Q CORROSION UNKNOWN Q OTHER <br />' y� CHECK ONLY <br /> WO UNDETERMINED Q SOIL ONLY Q GROUNDWATER Q ORINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z Q NO ACTION TAKEN Q PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED Q POLLUTION CHARACTERI7ATION <br /> H Q� iAK BEING CONFIRMED Q PRELIMINARY SITE ASSESSMENT UNDERWAY Q POST CLEANUP MONITORING IN PROGRESS ` <br /> v Q REMEDIATION PLAN Q CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) Q CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) 0 EXCAVATE!DISPOSE(ED) Q REMOVE FREE PRODUCT(FP) Q ENHANCED BIO DEGRADATION(IT) <br /> J f^M yKR FM MAIM <br /> e z QE5 Q CAP SITE(CD) Q EXCAVATE d TREAT(En Q PUMP d TREAT GROUNDWATER(GT)Q REPLACE SUPPLY(RS) (J-1 <br /> w a Q CONTAINMENT BARRIER(CB) ❑ NO ACTION REOUIRED(NA) Q TREATMENT AT HOOKUP(HLq Q. VENT SOIL(VS) <br /> Q VAC3UM EXTRACT(VE) Q OTHER(OT) <br /> W <br /> r <br /> - <br /> K as 4&9%' <br />