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UNDERGROUND STORAGE TAFK UNAUTHORIZED (LEAK) CONTAMINATION SITET <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES 10R.L ., At;AGENCY.USE ONLY <br /> .YES REPORT BEEN FILED 7 ®YES ® :NO <br /> jf1ERE8YCERTIFYTHATi HI►1iEDISTRIOUTEDTHISINFORMATION;AC DINGTOtHE <br /> pi$TRIBUTION SN N.. THE INUOT SHEET ON THE PAGE OI TNS FORM <br /> REPORT DATE CASE 3 <br /> d-7 dSIGNEII DATE <br /> NAME OF INDIVIDUAL FILING REPORT -PHONE SIGNATURE <br /> m v } 461 <br /> '� qj <br /> w REPRESEN G E OWNE ERATOR ® REGIONAL BOARD COMPANY OR AGENCY NAME <br /> PA R LOCAL AGENCY ® OTHER It C t <br /> A DRESS <br /> 3o4 6el-v� <br /> STREET CITY. STATE ZIP <br /> J NAME CONTACT PERSON <br /> PHONE <br /> zUNKNOWN L I Et <br /> N a ADDRESS �[ <br /> STREET CRY STATE IP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE 1 <br /> ® .. <br /> q ADDRESS <br /> O t <br /> w STREEP CITY COUNTY ZIP <br /> 1= CROSS STREET <br /> y <br /> a <br /> c7 LOCAL AG NCY , AGENCY NAME 'CONTACT PERSON PHONE <br /> z L i <br /> tiw f t�If1 <br /> wv <br /> w w REGIONAL BOARD PHONE <br /> ga. 1.\ <br /> NAME QUANTITY LOST(GALLONS) <br /> w <br /> w <br /> z ❑ UNKNOWN <br /> M.J <br /> m Z (1) <br /> UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ® INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lu <br /> w M D y y ® TANK TEST ® TANK REMOVAL OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> s UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> M D Y <br /> ui <br /> HAS DISCHARGE BEEN STOPPED 4 Q REPAIR TANK' CLOSE TANK&FILL IN PLACE F-�CHANGE PROCEDURE <br /> 0 YES ❑ NO IF YES,DATE ) ®' v REPLACE TANK O OTHER <br /> SOURCE OF DISCHARGE CAUSES) <br /> TANK LEAK UNKNOWN ® OVERFILL ® RUPTURE/FAILURE SPILL <br /> V PIPING LEAK OTHER ® CORROSION UNKNOWN OTHER <br /> V)w GH CK ONE ONLY <br /> CL <br /> V UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER [:] DRINKING WATER -(CHECK ONLY IF WATER WELLS NAVE ACTUALLY BEEN AFFECTED) <br /> C CK ONE ONLY <br /> 2 fn ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> iR <br /> Q a ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> V ❑ REMEDIATION PLAN '❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) 0 :CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) 0EXCAVATE&DISPOSE(ED) ® REMOVE FREE PRODUCT(FP) Q ENHANCED BIODEGRADATION(IT) <br /> IMe SACK MR MMM <br /> a,Q ❑ CAP SITE( CD) ❑ EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) RE CE SUPPLY(RS) <br /> Lu a E:] CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT OOKUP(HU) a VENT IL(VS) <br /> Q ❑ VACUUM EXTRACT(VE) OTHER(OT) <br /> IF V <br /> ;fig t l c r- c <br /> m <br /> z Fa r�. r' <br /> Nso 05(WR <br />