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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />€QRS LQCAI.AQ CY USE: QKY <br />REPORT BEEN FILED? <br />❑ YES NO El YES ❑ <br />I H R3EBS' AT( .THAT t AM. t =.1�AT(;1� G4u EMK YEE WRTHINT A HAVE <br />R R: F#!tS .(NFORMATIOV Tt? f QCAL F(G(Al 5, . „ „ .ANT ?0 SETK3Ni18d 7F. <br />REPORT DATE CASE i <br />......................................................................................................_.......... <br />_....... . <br />M D v r <br />NAME OF INDIVIDUAL FLING REPORT <br />« C, e A <br />PHONE SIGNATURE <br />® c <br />> <br />m <br />REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOAR COMPANY OR AGENCY NAME <br />LOCALAGENCY ❑ OTHER <br />IT!Mp�L-Tj+IS <br />a <br />s <br />ADDRESS <br />IJ ociz-7v 4" <br />i <br />TREET CITY STATE ZIP <br />NAME a <br />CONTACT PERSON <br />/PHONE <br />UNKNOWN <br />Qa <br />ADDRESS <br />/^" e a <br />.STREET ® CITY STATE ZIP <br />FACILITY NAME (IF APPLICABLE)OPERATO <br />PHONE <br />®f t <br />f `e <br />ADDRESSpv <br />ITRE CITY COUNTY ZIP <br />CROSS STREET <br />PE OF AREA ®COMMERCIAL ❑ INDUSTRIAL a RURAL <br />TYPE OF BUSINESSD RETAIL FUEL STATION <br />❑ RESIDENTIAL ❑ OTHER <br />❑ FARM ❑ OTHER <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />iQ09) <br />wr-3yzz <br />ugj <br />REGIONAL BOARD /PHONE <br />616 <br />vkwa <br />y <br />(t) NAME QUANTITYLOST (GALLONS) <br />I'me.UNKNOWN <br />(2 <br />_ <br />❑ UNKNOWN <br />DATE DISCOVEREDHOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />2 <br />M M o o y y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />MI MI DI DI Yl Yl UNKNOWN <br />Ix REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br />IHAS <br />❑ REPAIR TANK ❑ REPAIR PWING F-1 CHANGE PROCEDURE <br />DISCHARGE BEEN STOPPED? <br />o <br />YES ❑ NO IFYES.DATE M ml D o IY v <br />❑ OTHER <br />til <br />SOURCE OF DISCHARGE <br />TANK LEAK UNKNOWN <br />TANKS ONLYICAPACITY MATERIAL <br />GAL. FIBERGLASS <br />CAUSE(S) <br />❑ OVERFILL ❑ RUPTURE/FALURE <br />❑ PIPING LEAK <br />AGE YRS STEEL <br />❑ CORROSION X UNKNOWN <br />❑ OTHER <br />UNKNOWN ❑ OTHER <br />❑ SPILL ❑ OTHER <br />wW <br />CHECK ONE ONLY <br />$ <br />UNDETERMINED ❑ SOIL ONLY a GROUNDWATER 0 DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CH CK ONE ONLY <br />w❑ <br />SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />y <br />NO ACTKXN TAKEN ❑ POST cLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />z <br />❑ CAP SITE (CD) 0 EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />2 <br />❑ CONTAINMENT BARRIER (CB) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />❑ TREATMENT AT HOOKUP (HU) ❑ NO ACTION REQUIRED (NA) ❑ OTHER (OT) <br />f� 1(- <br />�e,�1Mt�1Qi el 1�fa, <br />'g r`4 <br />�s�:wlsmrl <br />r <br />