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a <br />/ HSC 05 (WO) <br />7 <br />/ �- <br />;2,03 <br />UNDERGROUND STORAGE TANK UNA W"" AK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICEES0 L GENCY USE OW[Y <br />-1 ❑ NO REPORT BEEN FILED Z <br />E PYTHA7I HAVE DISTRIBUTEDTHIS INFORMATION; ACCORDING TO THE <br />YES E:] YES ❑AEC <br />THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br />REPORT DATE CASE x NVI <br />SCI <br />ER!Y11 <br />j PER! <br />M Y 1 t_ <br />DATE <br />NAME OF NDIVID AL FILING REPORT <br />PHONE <br />SIGNATURE <br />m <br />r- '14 0. n <br />c (0) 04--026 <br />�, <br />LOU <br />REPRESENTING OWNERIOPERATOR ❑ REGIONAL BOARD <br />COMPANY OR AGENCY NAAE <br />cc <br />❑ LOCAL AGENCY OT//H''E��R <br />Co <br />cc <br />/ ► /-- <br />ADDRESSI,Ct l: � g0 <br />STREET CRY / STATE z)c <br />Lu <br />J <br />NAME <br />CO ��'© <br />CONTACT PERSON <br />7(110) <br />ONE <br />Z CC <br />LC UN Wil <br />l , r( • W /1 <br />9 ? -Q60 <br />ao a <br />W <br />ADDRESS <br />- ©x, c0®.3 g 4r%S qCITY <br />STATE <br />FACT ITY NAME (IF APPLICABLE) <br />OPERATO <br />PHONE <br />Z <br />0 <br />wq <br />ADDRESS / <br />re oL c `V /- � "l �� L/-1 Al <br />1 1 <br />CITY Zia <br />y <br />CROSS STREAL, <br />v S <br />OLOCAL <br />Zz <br />AGENCY AGEN Y NAME <br />CONTACT PERSON <br />PHONE <br />Lu <br />wU <br />w w <br />J U <br />REGIONAL BOAR <br />PH E <br />n a <br />----------------- <br />w <br />NAME (GALLONS) <br />U aJ <br />wzj <br />❑ UNKNOWN <br />(2) <br />❑ UNKNOWN <br />z <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MO ORING NUISANCE CONDITIONS <br />w <br />MI DI 42adylr <br />E]TANK TEST ❑ TANK REMOVAL <br />m <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />I <br />W <br />❑ UNKNOWN <br />❑ REMOVE CONTENTS [:]CLOSE TANK & REMOVE ❑ REPAIR PIPING <br />p <br />U <br />M D D <br />HAS�DISCHARGSTOPP Z <br />❑ REPAIR TANK ❑ CLOS TA FILL IN LACE CHANGE PR EDURE <br />O IFYES,DATE <br />REPLACE TANK OTHER 11 <br />M D Y Y <br />SOURCE OF DISCHARGEtAUSE(67 <br />a <br />U U <br />❑ TANK LEAK ❑ UNKNOWN <br />L <br />❑ OVERFILL ❑ RUPTURElFAILURE❑��THER <br />❑ PIPING LEAK ❑ OTHER <br />E:] CORROSION ❑ UNKNOWN "" J •� <br />Lu wa <br />CHECK ONE ONLYn O v P<a CA cit go( 1• <br />U <br />I ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER nt DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />w <br />❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />D ti ❑ <br />U <br />LEAK BEING CONFIRMED ❑ PRE ARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />❑ REMEDIATION PLAN CASE CLOSED ❑ CLEANUP UNDERWAY <br />J <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <br />(SEE SACK FOR WTAlS) <br />Z <br />0 0 <br />El SITE (CD) ❑ EXCAVATE & TREAT (ET) F -]PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />w a <br />❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) ❑ T ATMENT AT HOOKUP (HU) ❑ VENT S I S) <br />THER (OT) ( ` <br />❑ VACUUM EXTRACT (VE) ff <br />pkce-oe t' K Q raph ktl"a <br />U <br />/ HSC 05 (WO) <br />7 <br />/ �- <br />;2,03 <br />