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UNDERGROUND STORAGE TANK UNI YT RELEASE (LEAK) / CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOi i OCAt`AGENCY USE:ONIY : REPORT BEEN FILED 7 E::] YES [I� NO © �o .: , )HEREBY:CERTIFY THAT( HAV EDISTRIBUTEDTHISINFORMATIONACCORDINGTOTHE 0"T1ON SHOWN ON THE N)STRU, MON SHEET:ON THE BACK PAGE OF THIS FORK': REPORT DATE CASE s :: �j SIGNED DATE �J►� M <J r NAME OF INDIVIDUAL FMR RT PHONE to,)u SIGNATURE >- m c,. ) w REPRESENTING OWNE E R ❑ REGIONAL BOARD COMPANY OR AGENCY E cc S ❑ LOCAL AGENCY OTHER Q/ act g01D', ADDRESSS1 �` -0 f, A c M N�/ STREET cnr W\�CedVC4 STATE rv(vo3 J co NAME CONTACT PERSON PHONE w4o"�� z UNKNOWN 00. � ti c ADDRESS STREET cm STATE ZIP FACILITY NAME (IF APPLICABLE) Ol�cc� �rG,�' S�S6 OPE TOR PHONE z WCA� S cSQN () ba-� ►� U ADDRESS �� J W �1(. STREET CITY COUNTY V) MIZip ~ co CROSS STREET O z� zW LOCAL AGENCY AGENCY NAME �'aa Ca, kH CONTACT PERSON S�LO h- PHONE c Lu U �� t)� �_34a� M REGIONAL PHONE w O W0 Lu (1) NAME QUANTITY LOST (GALLONS) u Gt/Y1 S c J �Q/j EDUNKNOWN m z (2) :— ❑ UNKNOWN z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE M NITORING NUISANCE CONDITIONS dMI M D r ❑ TANK TEST ❑ TANK REMOVAL OTHER off am DATE DISCHARGE BEGAN (� METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) wO p - t ❑ UNKNOWN ❑ REMOVE CONTENTS ❑ CLOSE TANK 3 REMOVE ❑ REPAIR PIPING ❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PLACP CHANGE PROCED RE HAS DISCHARGE BEEN STOPPED 7 o YES E]NO IF YES, DATE 0-M ❑REPLACE TANK ( OTHER O S,tv -It -0 a SOURCE OF DISCHARGE CAUSE(S) ❑ TANK LEAK UN K U OVERFILL ❑ RUPTURE/FAILURE SPILL V V ❑ PIPING LEAK THER Z. ❑ CORROSION ❑ UNKNOWN ❑ OTHER tu ww0. CHECK ONE ONLY v ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION cc U) ❑ LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS U ❑ REMEDIATION PLAN E CLOSED EANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY J CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (R) (--eE d1CK FCR MALA wp ❑ CAP SITE (CD) E]EXCAVATE E TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) w a ¢ ❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION pE IRED (NA) ❑ TREATMENT AT k100KU (HU) ❑ VENT SOIL (VS) ❑ VACUUM EXTRACT (VE) OTHER (OT) U)/��jp�I LLJG Q� < 5 :D �%I-k &vc cif��S u�� waw AUW�K\� w `t/ \lk t _ m\ HSC 05 lea)