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qq- <br /> UNDERGROUND <br /> STORAGE TANK UNAUTHORIZED RELEASE (LEAK)!CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES .AOR LOCAL AGFNICY USE ONLY <br /> REPORT BEEN FILED z 1 HEREBY;CERT)FY:TkiAT HAVE DISTR1BUTfDTHIS INFOF13rIA710N ACCQITDiNG TOTHE <br /> ❑ YES NO ❑ YESNO <br /> DSSTH 18UT ON SHOWN ON Tk N'-60UC7101�5NNE�EQH 71{ BACK PAGE OF T}iIS FORM <br />` 1 77 <br /> REPORT DATE CASES <br /> h' s <br /> E 0. 3.1 Y/ sIGt1ED is <br /> DATE S <br /> V <br />! NAME OF INDIVIDUAL FILING REPORT PHONE SIGN RE _ <br /> �S3os 8'7�—qua <br /> m <br /> I 'LLI REPRESENTING -OWNERIOPERATOR ❑ ,REG_IONA_L BOARD COMPANY OR AGENCY NAME <br /> R <br /> ❑ LOCAL AGENCY Q OTHER 1 / { y V�" f��� <br /> f ti ADDRESS / 'P�L �I �f <br /> �f, STATE /�7 -� <br /> CC1AY rIP <br /> CONTACTPERSON PHONE <br /> w NAME �G +�1 7 7 H(� <br /> m T.,--T � UNKNOWN <br /> rA <br /> Z <br /> 31 <br /> G <br /> a ADDRESS <br /> d i V V 1/r V 1 STREET* 3 f L •S J�J V/ " f `wr W IP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR mf PHONE <br /> o <br />[: n ADDRESS /A� �{/(� [` ff�� } / /� <br /> V r � �� � �� [l (Z.'�iY�#`^ � CA4HTV 2lP r <br /> y CROSS ST,RJEET , <br /> V PHONE <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON <br /> w 0 �m joAQtA a c�� E,v�� nen.- -i r� 4LAA/ K�uc��-i— <br /> w REGIONAL BOARD PHONE <br /> uj <br /> IL <br /> M <br /> u) (�� <br /> NAME QUANTITY LOST(GALLONS) <br /> o KNOWN <br /> U u <br /> z UNKNOWN <br /> H <br /> E r DATE DISCOVERED HOW DISCOVERED 0 INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> zOTHER <br /> w '7 ,1 <br /> TANK TEST ED/fANK REMOVAL <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> 4 <br /> Eu D Y ❑ UNKNOWN ❑REMOVE CONTENTS LOSE TANK ak REMOVE ❑REPAIR PIPING <br /> tu HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK Q CLOSE TANK&FILL IN PLACE Q CHANGE PROCEDURE <br /> a �ES ❑ NO IF YES,DATE OM 3 �0 3 Y y REPLACE TANK OTHER <br /> SOURCE OF DISCHARGE CAUSES) = <br /> F-1TANKLEAK 1 UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> ❑ SPILL <br /> rOn o PIPING LEAK OTHER CORROSION [0-UNKNOWN ❑. OTHER , <br /> w w CHECK ONE ONLY _ <br /> VIL <br /> UNDETERMINED dSOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER-(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK E ONLY <br /> z �NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED Q POLLUTION CHARACTERIZATION <br /> cc LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑' <br /> POST CLEANUP MONITORING IN PROGRESS <br /> U y <br /> REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) � CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTIONS) EXCAVATE&DISPOSE(ED) Q REMOVE FREE PRODUCT(FP) ❑ ENHANCED BID DEGRADATION(IT) <br /> t p�B#ZK RM WFALM <br /> <Z CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP A TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> I CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT kOOKUP(FLU) ❑ VENT SOIL(VS) <br /> f � VACUUM EXTRACT(VE) ❑ <br /> OTHER(OT) <br /> Z <br /> w <br /> 8 <br /> Else 05 j"m <br />