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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />'POR LOCAL AGENCY VSE, ONLY <br />REPORT BEEN FILED? <br />Q YES NO Q YES ❑ NQ:IHEREBYCERTIFYTHAT1 <br />HAVE.DISTRIBUTEDTHISINFORMATiONACCORDINGTOTHE <br />QISTR IBU fKM($HOWN ON.THE:llVSTRUGTIDN SHEET:ON 7HE BACK PAGE OF THIS.FORM <br />. <br />REPORT DA <br />CASE A <br />SIGNEDDATE <br />M M v <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE , <br />w <br />¢ <br />REP SENTI El OWN PERATOR Q REGIONAL BOARD <br />NY OR AGENCY NAME % <br />LOCAL AGENCY Q OTHER <br />JZQ ff� t�!® thio <br />Q <br />A DRESS <br />304 uJ 3 r,4 <br />STREET STATE ZIP <br />w <br />J <br />NAME <br />CONT TPERSON <br />PHONEco <br />z <br />UNKNOWN <br />- <br />) <br />Ca <br />ADDRESS t`F <br />w <br />¢ <br />STREET CITY STATE IP <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />PHONE <br />z <br />) <br />O <br />¢ <br />o <br />ADDRESS <br />W <br />STREET CITY COUNTY ZIP <br />a -i <br />CROSS TREET <br />O <br />z� <br />1= w <br />LOCAL AGENCY AGENCY NAME <br />t n fl Uwet <br />CONTACT PERSON <br />PHONE <br />w O <br />of <br />aREGIONAL <br />BOARD <br />I <br />PHONE <br />c ) <br />LU 0 <br />W <br />(T9 NAME OUANTITY LOST (GALLONS) <br />Z <br />Q J <br />UNKNOWN <br />® O <br />(2) <br />UNKNOWN <br />z <br />z <br />DATE DISCOVERED <br />HOW DISCOVERED INVENTORY CONTROL. SUBSURFACE MONITORING Q NUISANCE CO DITIONS <br />MI MI o v v <br />❑ TANK TEST TANK REMOVAL OTHER C f (t) <br />m <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THA PLY) <br />Q <br />wml <br />Ij D1 Yl YJ UNKNOWN <br />F --j REMOVE CONTENTS Q CLOSE TANK & REMOVE F-� REPAIR PIPING <br />REPAIR TANK O CLOSE TANK & FILL IN PLACE F-1 CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED Z <br />U <br />o <br />YES 0 NO IF YES, DATE <br />NJ <br />REPLACE TANK a OTHER <br />1 M D D YJ vE:] <br />� <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />CC a <br />TANK LEAK ❑ UNKNOWN <br />� OVERFILL ® RUPTURE/FAILURE SPILL <br />y U <br />PIPING LEAK OTHER <br />CORROSION UNKNOWN F--] OTHER <br />U) d EC <br />ONE ONLY <br />v <br />UNDETERMINED SOIL ONLY GROUNDWATER E] DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />ECK ONE ONLY <br />w <br />� NO ACTION TAKEN Q PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED � POLLUTION CHARACTERIZATION <br />¢ <br />D ;5 <br />y <br />F-1LEAK BEING CONFIRMED a PRELIMINARY SITE ASSESSMENT UNDERWAY 0 POST CLEANUP MONITORING IN PROGRESS <br />U <br />F --j REMEDIATION PLAN CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) 0 CLEANUP UNDERWAY <br />J <br />CHECK APPROPRIATE ACTION(S) r --j EXCAVATE & DISPOSE (ED) 0 REMOVE FREE PRODUCT (FP) ENHANCED BIODEGRADATION (ITL <br />(SEE BACK FOR DETALS) <br />00 <br />El CAP SITE (CD) F-� EXCAVATE & TREAT (ET) E:j PUMP & TREAT GROUNDWATER (GT) O REPLACE SUPPLY (RS) <br />w c <br />F-1CONTAINMENTBARRIER (CB) E] NO ACTION REQUIRED (NA) TREATMENT AT HOOKUP (HU) VENT SOIL (VS) <br />¢ <br />F-� VACUUM EXTRACT (VE) OTHER (OT) <br />og <br />U <br />HSC 05 (89% <br />-it <br />a <br />