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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERV I) <br /> REPORT BEEN FILED 9 FGR'LOCAL:AGENCYIUSE ONLY <br /> ❑ YES No ❑ YES ND l HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACC RDiNG TO THE <br /> /REPORT DATE CASE at DI 7)ON SH UCTION SHEET ON THE BACK P E OF-TH ORM. <br /> -1 7-1 <br /> SIGRED AT <br /> NAME OF IN DIV UAL FILING REPORT - DAT <br /> PHONE :i SIGNATU <br /> � �Fn <br /> Lu <br /> OWNERrOPERATOR ❑RE=GENCYOTHER <br /> ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> W i/P�r�L Ilk. <br /> ❑ � , J CC7erty � <br /> Q ADDRESS <br /> . l ?r Zov ate- Ta1�1 II s G4 � zo <br /> STREET CTI + �� <br /> NAME STATE 21P ) <br /> �y / -� CONTACT PERSON I{ !PHONE f <br /> Z¢ J' C�� �G1��. UNKNOWN llr1 `�f � ir� <br /> cLa ADDRESS <br /> Lu <br /> STREET CITY I STATE Np <br /> FACILITY NAME(IF APPLICABLE) , <br /> OPERATOR li PHONE <br /> Z 7 DG-f>Sv } <br /> 0 <br /> U ADDRESS <br /> W �� 5- STREET�� <br /> cm j E l <br /> =UNTY ZIP <br /> CROSS STREET <br /> v'; ILI, <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON i ` <br /> z PHONE <br /> W <br /> REGIONAL BOARD PHONE <br /> a a i. <br /> Gcj3> ( } <br /> LU (t1 NAME �E QUANTITY LOST(GALLONS) <br /> w !f <br /> Z <br /> UNKNOWN I <br /> m (2) �I l <br /> N <br /> UNKNOWN <br /> w DATE DISCOVERED Q HOW DISCOVERED F7I TORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w UMI MI o {v y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> m BATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a d ih i <br /> R v y UNKNOWN ❑REMOVE CONTENTS LOSE TANK 5 REMOVE ❑REPAiR PIPING <br /> U HAS DISCHARGE BEEN STOPPED 7 REPAIR TANK ❑6LOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o Y£S ❑ NO IF YES,DATE I ❑REPLACE TANK 4 ❑ OTHER <br /> M q Y Y <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> Lu <br /> o U F-1 TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUP i� E(FAILURE ❑ SPILL <br /> y ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> II <br /> N wa CHECK ONE ONLY <br /> U ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER •(CHECK ONLY SF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK PWONLY <br /> wNO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITt'ED If ❑ POLLUTION CHARACTEAiZikTION <br /> y ❑ LEAK BEING CONFIRMED F--] PRELIMINARY SITE ASSESSMENT UNDERWAY ! p POST CLEANUP MONITORING IN PROGRESS <br /> U ' <br /> REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY)) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION($) ❑ EXCAVATE S DISPOSE ❑ ( ) (Y) <br /> INEaACKFMOETtis1 (ED) REMOVE FREE PRODUCT FP ❑ ENHANCED BIO DEGRADATION I <br /> p ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(€T) ❑ PUMP 6 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REouisED(NA) E::] TREATMENT AT HOOKUP(HU ) ❑ VENT SOIL(VS) f+ <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> /Qi//�tv dFl4. RES�L'T� �Nla�� r� svi4, coov-r44uNi Ioh( Fiea,4c -7- <br /> w 41N 513+)In I- Flel, -f� 5.1 Tr "'Lr PIE. r?EaL.,/r Tv <br />