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AWL 4 <br /> UNDERGROUND STORAGE 1114K UNAUTHORIZED RELEASE (LEAK)/'CONTAMINATION SITE REPORT <br /> EME GENCY HAS STATE OFFICE OF EMER ENCY SERVICES FOR LOCAL AGENCY USE.ONLY <br /> REPORT BEEN FILED? :;,I.fiEREBY CERTIFYTHAT I,HAVE'DiSTRiBU i ED THIS INFORMATION ACCORDING TO THE <br /> YES ® NO YES ❑ NO <br /> DISTRIBUTION SHOWN ON THE:INSTRUCTION SHEETAN THE BACK PAGE OF THIS FORM. <br /> REPORT DATE CASE <br /> M M v SIGNEII. DATE <br /> N OF NDIVIDUAL FILING REP PHONE SIGNA <br /> !�k <br /> � ) <br /> w REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARDC MPA <br /> CONTACT PERSONNY OR AGENCY NAME <br /> °C LOCALAGENCY ❑ OTHER61'o'lk 614=&24" <br /> ¢ ADDRESS f 9s <br /> REEF CITr STATE ZIP <br /> W NAME PHONE <br /> z ❑ UNKNOWN } <br /> 04 <br /> Q-a ADDRESS <br /> w <br /> cc <br /> C t STATE IP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR g y PHONE <br /> 17 <br /> z <br /> O Y-5 Zi�ikcl <br /> V ADDRESS <br /> W <br /> C HTY ZIP <br /> CROSS STREET <br /> I��"/ Z 2: <br /> LOCAL AGENCY AGENCY E CONTA TPERSON PHONE <br /> z W <br /> a< REGIONAL BO D PHONE <br /> c 7 <br /> y (9p NAME QUANTITY LOST(GALLONS) <br /> Z wae;� 6�zLei/ ❑ UNKNOWNco <br /> z (2) <br /> �— <br /> ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ S BSURFACE MONITORING UISANCE CONDITIONS <br /> M� oI o) v y E] TANK TEST ❑ TANK REMOVAL OTHER = 6p <br /> �e_ _E\ <br /> mDATE DISCHA GE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) -� <br /> a1-9 <br /> Q ® UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE E:]REPAIR PIPING <br /> W M o Y r <br /> pM D Y <br /> HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TA FILL IN PLACE CHA GE PROCED E <br /> 0 <br /> o YES E:] NO IF YES,DATE > Y ❑REPLACE TANK OTHER11111/ <br /> 'a SOURCE OF DISCHARGE CAUSE(S) <br /> uJ <br /> a ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL F-1RUPTURE/FAILURE ❑ SPILL <br /> w 0 PIPING LEAK EZ OTHER ❑ CORROSION ❑ UNKNOWN OTHER <br /> w w CHECK ONE ONLY <br /> o ❑ UNDETERMINEDSOIL ONLY ❑ GROUNDWATER [:] DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> zw ❑ NO ACTION TAKEN Q PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> � LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> C"0 ❑ REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) E] EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> J (SEI a9CK PM MAILS) <br /> F3 p❑ CAP SITE(CO) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> wF- <br /> w< ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIR D(NA) TRE TMEN'T AT HOOKUP(HU) ❑ VENT IL V ) A <br /> w <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) ( �/ <br /> zvew <br /> U ' <br /> HSC O5 MW <br />