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UNDERGROUND STORAGE TANK UNAUTHORIZED REL E ASE(LEAK) CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCYSERVICE <br /> FOR:: Y.:"US.E ONLY <br /> ❑ LAGENC <br /> No <br /> REPORT BEEN FILED? <br /> �,f.l ERR. m. p ral 1�: <br /> YES YES NO - <br /> JITIN <br /> REPORT DATE <br /> CASE <br /> 1-1 Z-1 qyj oJ - SIGNED::`-- <br /> NAME OF INDIVIDUAL FILING REPORT PHONE, SI R <br /> REPRESENTING OWNr COMPANY OR AGENCY NAME' <br /> OWNER/OPERATOR ❑ REGIONAL BOARD <br /> ir /I <br /> 0 0LOCAL AGENCY ❑ OTHER 7 <br /> uj 1� <br /> ADDRESS --7 <br /> 82 <br /> ET CITYBTATE <br /> E CONTACTIOERSON PHONE <br /> zZIP <br /> 7� Masi/A caey� OWN Aj?7fL�45- <br /> 4' <br /> RADDRESS <br /> R <br /> STREET <br /> ul <br /> erry STATE 21P <br /> FAC�TY NAME(IF APPLICABLE) OPERA /' <br /> C <br /> PHONE <br /> L <br /> ADDRESS <br /> 91, STtR/e F T erry CCXJNrY ZIP <br /> CROSS STREET <br /> -F90-5A)0 <br /> 3 co LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> Lu <br /> REGIONAL BOARD <br /> PHONE <br /> Lu <br /> NAME OUANTITY LOST(GALLONS) <br /> �. <br /> Zf7 1-1&-lU15 --L NKNOWN <br /> 0 UNKNOWN <br /> DATE DISCOVERED HOWOiSCOVERED <br /> z INVENTORY IDONITROIL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lu <br /> /.I TAW TEST "'TANK REMOVAL ❑ OTHER. <br /> it DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> I ml .1 01 11 .11 E3-09WOWN Ca-411-MOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> > HAS DISCHARGE BEEN STOPPED? F-1 AIRTANKREPAIR PIPING ❑ CHANGE PROCEDURE <br /> o Rr-lZS D NO F YES.DATE I ml ml L-1 Z-01 9,1 n <br /> SOURCE OF DISCHARGE CAUSES) <br /> §a F--] TANK LEAK OVERFILL ❑ RUPTURFJFAILURE ❑ SPILL <br /> CORROSION ❑ OTHER <br /> E:] PIPINGLEAK El OTHER ❑ D-MTJOWN <br /> tu w CHECK ONE ONLY <br /> ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER F--j DRINK NG WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Lu <br /> F-] NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN BMnTED POLLUTION CHARACTERIZATION <br /> 9 <br /> Ir LEAK BEM CONFIRMED PRELWiNARYsrm ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> in F <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTiON(S) F7 EXCAVATE DISPOSE(ED) REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIC)DEGRADATION(M <br /> z PXEnACKFORMTOAM <br /> LU 4 CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) C:l REPLACE SUPPLY(RS) <br /> c'w CONTAINMENT BARRIER(CEI) ❑ NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑c <br /> VACUUM EXTRACTIVE) ❑ OTHER(OT) <br /> �or 2k� <br /> Y <br />