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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES No REPOR70EEN FILED ❑ YES ❑ NO 1 HEREBY CERTIFYTHATL HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTO' SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE R CASE• ` ` �. —^��' <br /> D L 5 <br /> v SGNFD DATE. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> 20f) f7f <br /> w REPRESENTING ❑ OWNERIOPERATOR ❑ REGIOAL BOARD COMPANY OR AGENCY NAME <br /> ¢ LOCAL AGENCY ❑ OTHER <br /> 8 <br /> a ADDRESS /pJ <br /> l 0 1 6o neer cm (�l'1 3FA1e' �✓ "iip <br /> j NAME <br /> y CONTACT PERSON / PHONE <br /> /S / 74C <br /> F (q N <br /> 2 a <br /> n yADDRESS Vp <br /> FACILITY NAME(IF APPLICABLE) b OPERATOR ACNE <br /> Ghsn. c <—l'b sT :57A-IkA,f-- c y7-03 <br /> ADDRESS � ) <br /> y CROSS STREET <br /> O LOCAL AGENCY AGENCY NAME CONTACTPERSON PHONE <br /> z" <br /> REGK)N BOARD PHONE <br /> y (t) NAME OUANTTTY LOST(GALLONS) <br /> y� k dYb�f42�On1 ❑ <br /> j UNKNOWN <br /> Z (2) <br /> �— <br /> y ❑ <br /> UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ S�JUjgj��U(p ACE MONITORING ❑ NUISANCE CONDITIONS ` <br /> TANK TEST ❑ TANK REMOVAL piHER L <br /> D of Y <br /> m Ex <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY)) <br /> w <br /> Ml d DI Y1 A ❑ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVEWREPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE❑CHANGE PROCEDURE <br /> O <br /> o ❑ YES ❑ NO IF YES,DATE MI a oI Y1 r ❑REPLACE TANK ❑OTHER f <br /> u1 SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUflFhAILURE ❑ SPILL <br /> ❑ PIPING LEAK OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> yw CHECKONEONLY <br /> O UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> HECK ONE ONLY <br /> w� ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> �y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATES DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCEDBIODEGRADATK)N(IT) <br /> �vcR sm oErwt <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMPS TREAT GROUNDWATER(GT) REPLACE SUPPLY IRS) <br /> w ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED MA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT BOIL(Va) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> "ThP✓ CI ry k Na{ s v a�MN <br /> re_�n i o r4 AGI <br /> $ 64 f�,rzs m b€ r µiced <br /> s — <br /> Xx m lA'oN <br />