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R <br />j 1 • •' •' •: ,•. <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES AL AGENCY USE pNLY.x. <br />❑ YES REPORT BEEN FRED ? a YES (HEREBX CERT 7HA7 t HAVE DISTR UiB!I --....... A7x3N AGGOHDWG fC? THE <br />:aST�uTtcrvr�rok 1 HFsiRucit sHT+e aACK PaG o� THS SRM <br />REPORT DATE CASE <br />NAM OF INDIVIDUAL FILING REPORT <br />PHONE <br />S R <br />m <br />o lew 9 I. �G a <br />(5w) Lf) -o 331(0 <br />REPRESENTING ❑ OWNER/OPF-R^ TOR ❑ REGIONAL. BOARD <br />COMPANY OR AGENCY NAME <br />❑ LOCAL AGENCY ©OTHER e6VSc.t� jam/ Z- <br />CC <br />ADDRESS <br />i+/[ �® �)' / /A��` % y��� f��J <br />- <br />O' t K Cjr <br />l ° O�! �8T' t/ CfTY l I STATE 1 ZIP <br />w <br />NAME ( <br />CONTACT PERSOON� <br />co <br />z <br />//.. // <br />Al A S � W� ❑UNKNOWN <br />/PHONE <br />Q <br />a <br />Lu <br />2 <br />ADDRESS <br />(% /j� <br />N S C <br />(/C <br />` 1i STREET CRY ` STATE IP <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />PHONE <br />C>I�e„ r - b� Se -(v S t, <br />�?�9) - ??3- Z Z13 <br />o <br />ADDRESS <br />Lf <br />N " k s-11— <br />w <br />STREET w CfTY COIINTY ZIP <br />t <br />rn <br />CROSS STREET <br />p <br />W al <br />LOCAL AGENCY AGENCY NAME <br />S -u cc <br />CONTACT PERSON <br />PHONE <br />7' < <br />REG NAL BOARD <br />V / <br />PHONE <br />N7n /)Z a / Cllyl <br />01 � ) � <br />m <br />(�I NAME QUANTITY LOST (GALLONS <br />�t(a UNKNOWN <br />z <br />(2) <br />H <br />❑ UNKNOWN <br />uj <br />/DATE DISCOVERED <br />O t <br />;LM ®4 <br />HOW DISCOVERED Q INVENTORY CONTROL. ❑ SUBSURFACE MONITORING ❑ / NUISANCE CONDITIONS <br />OTHER <br />`y -1 y <br />❑ TANK TEST ❑ TANK REMOVAL <br />DATE DISCHARGE BEGAN-,/UyKf�WN <br />METHOD USED TO STOP DISCHARGE (CAECK ALL THAT APPLY)Q <br />1 <br />I� <br />® REMOVE CONTENTS Q CLOSE TANK S REMOVE REPAIR PIPING 1 <br />REPAIR TANKED TANK &/Fja l W PLACE CHANGE ROCEDURE <br />0 <br />HAS DISCHARGE BEEN STOPPED ? <br />p <br />[3 ' ES E] NO IF YES. DATE VM b P <br />❑ REPLACE TANK OTHER ! i <br />v v <br />w <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />a <br />❑ TANK LEAK UNKNOWN <br />❑ OVERFILL ❑ RU TURE/FAILURE ❑ SPILL <br />Ci <br />❑ PIPING LEAK ❑ OTHER <br />® CORROSION UNKNOWN Q OTHER <br />u, w <br />CHECK ONE ONLY <br />V <br />❑ UNDETERMINED ❑ SOLI ONLY GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) , <br />CHECK ONE ONLY <br />rz 0 <br />❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />❑ LEAK BEING CONFIRMED ® PRELIMINARY SITE ASSESSMENT UNDERWAY Q POST CLEANUP MONITORING IN PROGRESS <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTION(S) EXCAVATE S DISPOSE <br />RW eAWFURO:r� ® (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED 810 GRADATION (IT) i <br />8 <br />❑ CAP SITE (CO) F-1EXCMP Ni AVATE & TREAT (ET) ❑ PUTREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />4 <br />❑ CONTAINMENT BARRIER (CB) Cl ACTION REQUIRED (NA) E:] TREATMENT AT HOOKUP(POLL) VENT SOIL (VS) <br />❑ VACUUM EXTRACT (VE) OTF�R (OT) /I �,�,i 4 66 AN W " / <br />W <br />NSG W tw w <br />