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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCYHAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> F-1 VES NO <br /> REPORT BEEN FLED? [–] YES ❑ NO 1 HEREBY CERRFYTHATI:HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE WSTA TIDN SHEET EBACK PAGE OF THIS FORM <br /> 7/REPORT lE CASE 4 CJS ` / ' <br /> SIGNED ( DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> 1 a . SAIAV c w3 Zo <br /> w REPRESENTING ❑ OWNER/OPERATORREGIONAL BOARD COMPANY OR AGENCY NAME L� <br /> S LOCAL AGENcy E::] OTHER kJA/ I.I/K Ka-) <br /> c ADDRESS <br /> Q o <br /> w NAME /J CONT TPERSON /J PHONE <br /> i <br /> E::]QF�VJ UNKNOWN <br /> d a ADDRESS —] y+/� `�T <br /> 1 7 � '.T... I -e � � cm J �Q� T. <br /> e � P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS Q �] w <br /> No 7V cm ✓ wurmTl nv <br /> y CROSS STREET 1.' <br /> W <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> ww �S <br /> REGIONALBOARD PHONE <br /> w G �9ldi S60 <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> 41tw O <br /> r lea Lo tj5 ❑ UNKNOWN <br /> m� m <br /> m ❑ UNKNOWN <br /> i DA,T,E1 D`I�J.OVEREO 9 HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS 1 <br /> �I 1 M o o� (v v ❑ TANKTEST TAN KR MOVg4_ ❑ OTHER <br /> QDATE DISCHARGE BEGAN OO USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) —V <br /> wM o v v UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED 7 y <br /> 11 ❑REPAIR TANK CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> S ❑ YES E] NO IF YES,DATE M wd o v v ❑REPLACE TANK OTHER I�-Q <br /> SOURCE OF DISCHARGE CAUSES) <br /> 'IN F-1 TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> t <br /> wO ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> ww CHECKONEONLY <br /> X UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> ¢� ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> jy ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> �e!a�rw oEiYHI <br /> ZCAP SITE(C <br /> WO ❑ D) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)E::] REPLACE SUPPLY(RS) <br /> w< ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED INA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENTSOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> z Sai L fpr/ N!<�✓�ln o^J 05reJ,w7 Z— U _ l 7 �r�y�,_o veal <br /> o <br /> /S-f'2 Fuzee' Sim- a-n'+'sSdu � G✓i GG. � � <br /> 8 CoN7�A4;tV f O/✓ uiieeel 6 i8 LLP .'m rc� `` <br /> NBC <br />