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UNDERGROUND STORAGE ANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVK:ES S FOR LOCAL'AGENCY USE ONLY <br /> ❑ YES ® NO REPORT BEEN FILED? ❑ YES NO I HEREBY CERION BHOWNCN HAVEHE DISTRIBUTED <br /> ON THIS <br /> ONTRHEA9ACK ACCORDING <br /> AGE OFTHIS THE <br /> ORM <br /> REPORT DATE CASE:1 <br /> VMI M d / r SIGNED - DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> w REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> S LOCAL AGENCY E:] OTHER nTOu drn ��' (U�7�« Hck Seg-v/Cr <br /> ¢ ADDRESS <br /> Soy £• c-k -/-v., Com} 9sao/ <br /> 3TNEEf CRY STATE ZIP <br /> NAME <br /> Z CONTACT PERSON PHONE <br /> UNKNOWN Love /��p J ! <br /> �(Ms <br /> OQ <br /> w¢ ADDRESS <br /> CTREET cm STAT IP <br /> PHONE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR <br /> o <br /> ti ADDRESS <br /> � s�o( /Gw 13 d P� le <br /> w Cm (=WY <br /> P <br /> I- CROSS STREET <br /> y <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w REGIONAL BOARD PHONE <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> w0 <br /> <J [j�-�KNOWN <br /> m (2) <br /> yz <br /> 1NKNOWN <br /> Z <br /> DATEDISCOVEREDDISCOVEREDHOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING E] NUISANCE CONDITIONS <br /> w OMI p MI �`-I ;L--I Y� Y I--] TANK TEST TANK REMOVAL ❑ OTHER <br /> r <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> 2 ,� UNKNOWN ❑REMOVE CONTENTS CLOSE TANK b REMOVE ❑REPAIR PIPING <br /> w M o r r <br /> i7 HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK b FILL IN PLACE ❑CHANGE PROCEDURE <br /> J <br /> o ❑ VES [:] NO IF YES,DATE MI jo Y Y ❑REPLACE TANK C:] OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> a ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> y U ❑ PIPINGLEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> yp <br /> O UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> iNOACTIONTAKEN ❑ PRELIMINARYSRE ASSESSMENTWORKPLAN 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 UNOERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE b DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> 1�acit iw oETAl91 <br /> 5 p ❑ CAP SITE(CO) ❑ EXCAVATE b TREAT(ET) ❑ PUMP b TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w� <br /> w< CONTAINMENT BARRIER(CS) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(Ys) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> FUr-jqL. "one Inns-ey 7(v dee m.,Z, *L&-i� a.A� <br /> L�IC-�GN� Lo�) �on.�G-.n r.�-a- vti AatS t¢Gr^l vrh�� siy tor-a-0 I-C <br /> U �Q l o h S r��f c.1 G if !yQ [0.7'1✓ia-2G/ �� �f{'.f-�t7FiJ _ / T J <br /> «sc ns Ie9ol <br />