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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGE NgI SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES ZREPORT BEEN FILED T �'Y/ES ❑ NO (HEREBY�ERTJR:THAT I ANE A OE&IGNATEII Gt VERNMENT Cm%9YEe}AND THAT E({AVE:. <br /> REPORTED THIS INFORMAT.IPJ4 TO E QCAL#FIC. PtlfiSllANT T(}SEGTJON 2S19Q 7 OF <br /> REPORT DATE CASES ;.THE#i.,.::.. :::0..... ODE ::'::;>;:;:5;:_:::::c">:`;:>>:i:;i:>::...;:;;;::::.<>: <br /> 4 <br /> M L�ml qyl yl <br /> >::;;>:;?i>:%.:::. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNA RE <br /> � `� Re's � zl6e-13{3 <br /> cl <br /> RE��m COMPANY OR AGENCY N E <br /> ❑ OWNER/OPERATOR ❑ REGIONAL BOARDaENCY ❑ OTHER s 1)'� / <br /> cc ADDRESS (/ <br /> P,0. oo STREET CRY C7s-lecr� cis me <br /> SPATE np <br /> Ed <br /> w NAME O CONTACT PERSON PHONE <br /> `� ❑ UNKNOWN <br /> a <br /> a ADDRESS <br /> w <br /> g a 3 w G% � 7 4U%tecw (33 cf� 9 � <br /> STREET CRV SrAlm rp <br /> FACILITY NAME(F APPLIC LE) OPERATOR pHONE <br /> U ADDRESS <br /> VU <br /> O , COUNTY ZIP <br /> � C <br /> cm <br /> CROSS STREET <br /> LOCALAGENC AGENCY NAME CONTACTPERSON PHONE <br /> W Z c Ps - D. <br /> ZZ <br /> REGIONAL � PHONE <br /> i <br /> m (�) a NAME QUANTITY LOST(GALLONS) <br /> w � <br /> F w UNKNOWN <br /> m (� <br /> w <br /> ❑ UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ BSURFACE MONITORING ❑ NUISANCE GOND S <br /> w <br /> Q o f ( ❑ TANK TEST ❑ TANK REMOVAL OTHER, AAA J7,970 <br /> M M D D Y Y <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT Y) <br /> ml D1 -01 yl UNKNOWN Ep"'4EMOVE CONTENTS ❑ REPLACE TANK �CLOSE TANK <br /> HAS DISC RGE BEEN STOPPED Z ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> o YES ❑ NO IFYES,DATEQM �D 7D FYIl iY ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> j ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> $O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> ma <br /> ❑ UNDETERMINEDSOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK NLY <br /> w Q NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED E] POLLUTION CHARACTERIZATION <br /> cc <br /> Ir <br /> col <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION ❑ ❑S) EXCAVATE 8 DISPOSE(ED) REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> 1!£EB,=FwwT" l <br /> w Q❑ CAP SITE(CD) ❑ EXCAVATE d TREAT(ET) ❑ DUMP a TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) / 1 <br /> �a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) W <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> Lu <br /> ssc�s 8�� <br /> HSCOS(11/0 <br />