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i <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / C <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES I ` FOR LOCAL AGENCYdUSE.ONL: <br />�/ REPORT BEEN FILED? 1101 NO I HEREBY CEFmFYnAT (l iWiE Di: <br />I VI un YES E] . rw TUG imm <br />s ADDRESSCA l 5O[ LJ �, <br />i <br />STREET C(Pf Ii .I.- STATE 21P <br />CONTACT PERSON ; PHONE <br />J NAME// `< , <br />N VV sf "� ❑ UNKNOWN V 1✓ ! 1GL ! t, �I�F�J���/� - <br />O <br />ADDRESS <br />—/.j� n os(�'� ! SCrM �' f.U//i�W✓a��tl " <br />CL CITY <br />ST TIP CJ <br />STREET <br />FACILITY NAME (IF PLICABLE) <br />a. s. ,� <br />q ADDRESS 313 1 r� [srRa D e <br />LL. <br />y CRO TREE <br />OPERATOREE <br />PHONE <br />[ai <br />COUNTY <br />95aoo��fr <br />i LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br />?0 y ]l <br />off 3 '" 00 <br />W L PHONE <br />Rr AL BOARD <br />R c1(3 yl� <br />j3 <br />� {�) NAME QUANTITY LOST (GALLONS) <br />U w ( T Tt� UNKNOWN <br />Z l� <br />y4 J n <br />Z (Zi ' l L �J UNKNOWN <br />DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ! SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />Z r <br />TANK TEST TANK REMOVAL OTHER <br />l'r ®D DI 9N ryY <br />❑ <br />a <br />DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARG (C ECK ALL AT APPLY) <br />m 1! <br />} UNKNOWN ❑REMOVE CONTENTS CLOSE TANK & REMOVE ❑ REPAIR PIPING <br />Lu .1 YlHAS DISCHARGE BEEN STOPPED 7 r ❑ REPAIR TANK II E::] CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE <br />0 YES ❑ NO IF YES, DATE�Y Y ❑REPLACE TANK } ❑OTHER <br />SOURCE OF DISCHARGE CAUSES) <br />a fO ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUP,TURElFAILURE SPILL <br />Z) �__�,{ <br />h L'CI PIPING LEAK OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br />y w� <br />'r <br />CHECK ONE ONLY <br />SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />[ai <br />❑ UNDETERMINED <br />CHECK ONE ONLY <br />j{ <br />z rn <br />NO ACTION TAKEN ❑ <br />PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />❑ LEAK BEING CONFIRMED ❑ <br />PRELIMINARY SITE ASSESSMENT UNDERWAY <br />❑ POST CLEANUP MONITORING IN PROGRESS <br />U <br />❑ REMEOIATION PLAN ❑ <br />CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br />ig <br />CHECK APPROPRIATE ACTIONS) <br />❑ EXCAVATE &DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED B!O DEGRADATION (IT) <br />a Z <br />E3 <br />❑ (eac c Frn o�,nnsi <br />CAP SITE (CD) <br />❑ EXCAVATE & TREAT (EI) El PUMP & -TREAT GgOUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />O <br />FI,. <br />w a <br />❑ CONTAINMENT BARRIER (CB) <br />❑,! NO ACTION REQUIRED (NA ❑ TREATMENT AT HOOKUP (HU)❑ VENT SOl (VS) <br />❑ VACUUM EXTRACT (VE) <br />%� <br />OTHER <br />, <br />L) <br />HSC 05 W901 <br />t'I <br />i+ <br />i � I, <br />