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NDERGROUND STORAGTA1VK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT ' <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />FQR.COCAC,AGENCY USE.OK :. <br />REPORT BEEN FILED ? <br />❑ YES ❑ NO :YES ❑ NOIRIQIE7I�.tS}�OYYJ��C��iET <br />1t1EAEBY CEAf. I.FEAT #}iAVE:DISTRIBUfiEQTHISINFORMATIONACCORDING TOT#iE <br />REPORT DATECASE x <br />ON 7HE SACK PAGE OFiH FQAM <br />j t i.' <br />-: - <br />M MI v , <br />..SKiNED .. <br />DATE*:'::. . <br />NAME OF INDIVIDUAL FILIyG REPORT <br />PHONE . <br />SIGNATURE <br />m <br />i 1"/ <br />w <br />REPRESENTING OWNE44OPERATOR ❑ REGIONAL BOARD <br />COMPANY OR AGENCY NAME, <br />{ <br />p❑ <br />LOCAL AGENCY ❑.: OTHER <br />",,� ;.,,. f <br />(-�^e <br />¢ <br />1�.�'.;,� <br />r''��'y..(' <br />�s +'gym. <br />ADDRESS & <br />) <br />° ✓ ~f t.fa+ <br />c✓v 1 <br />_ <br />REIT - CITY STATE ZIP <br />wNAME <br />C) y { f <br />17. <br />CONTACTPERSON <br />PHONE <br />z❑UNKNOWN <br />L <br />n0. cn a <br />ADDRESS <br />¢ <br />rJ <br />STREET CITY STATE ZIP <br />O <br />FACILITY NAME (IF APPLICABLE) <br />a <br />•{�*� {j ..." t <br />gw.:. tw.+ "'°ks: <br />j <br />OPE OR <br />+2 <br />PHONE <br />r <br />\ .. V - "^".• " j YR7 <br />~ aOADDRESS <br />." <br />'� ! <br />W <br />STREET CRY COUNT Y 21P <br />CROSS STREET <br />y <br />O <br />z <br />w <br />LOCAL AGENCY, AGENCY NAME <br />( / <br />t[ <br />CONTACT PERSON <br />PHONE <br />'"3 <br />1 . 1 ,F <br />w w <br />REGIONAL BOA-Rqf <br />PHONE <br />CL <br />w <br />W <br />(1) NAME QUANTITY LOST (GALLONS) <br />r <br /><> <br />/+❑ UNKNOWN <br />t ." <br />U) 01 <br />z_ <br />(2) <br />❑ UNKNOWN <br />Z <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE M60TORING ❑ NUISANCE CONDITIONS <br />w <br />I <br />❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br />MI E MI D Y <br />m <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />>❑ <br />_ <br />UNKNOWN <br />❑ REMOVE CONTENTS ❑CLOSE TANK &REMOVE ❑REPAIR PIPING <br />¢ <br />p <br />M M D Y <br />❑ REPAIR TANK ❑ CLOSE TAN(I(� ILL IN LACE CHANGE PR DU <br />HAS DISCHARGE BEEN STOPPED 4 <br />❑ YES ❑ NO IF YES. DATE <br />❑REPLACE TANK OTHER . { f Fi <br />o <br />(AmlMI Y <br />SOURCE OF DISCHARGE <br />CAUSE(S) fIy <br />a <br />❑ TANK LEAK ❑ UNKNOWN !. <br />E]OVERFILL E]RUPTURE/FAILURE ❑ SPILL 4 Y tLAe <br />� <br />N o <br />F-]PIPINGLEAK F -] OTHER❑ <br />CORROSION ❑ UNKNOWN ® OTHER <br />Lu w <br />CHECK ONE ONLY - <br />v �: <br />❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />z <br />❑ NO ACTION TAKEN F --]PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED E::]POLLUTION CHARACTERIZATION <br />¢ a <br />❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />O <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />J <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />(SEE BACK FOR OE7ARSi <br />`5 z <br />❑ CAP SITE (CO) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />w < <br />❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) ❑ TRFiMENT AT HOOKUP (HU ❑ VENT SOIL (VS) <br />¢ <br />u,, <br />VACUUM EXTRACT (VE) ❑ OTHER (OT) <br />z <br />� � 1, i" <br />o <br />! <br />Gi' Gfl <br />11 <br />0 <br />