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w)5 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY ; HAS STATE OFFICE OF EMERGENCY SERVICESL.00AL'AGENCY USE ONLY <br /> ❑ 1yr,., REPORT BEEN FILED? ❑ NO 1}IfFEBYC RTIFYTkYA�' <br /> YES FRAV ISFR1Bt}TEQTH WFCRAu31oF1'A CORQu[CiTOTHE`. <br /> •�J {SfR�tlt10N$HOVYN T �t57AlJCTM SF d. TH <br /> 0' E WX PAGE joFTtBS kMR <br /> REPORT DATE CASE II a .. <br /> V D BpMED >: Oi1TE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> m A 1 tison S <br /> REPRESENTING ❑ OW4940OPERATOR ❑ REGIONAL BOARD I COMPANY OR AGENCY NAME <br /> R LOCAL AGENCY F] OTHER V r <br /> ADDe P�PX AW*Uk-Q Y—s <br /> STREET crry STATE zip <br /> oa NAME CONTACT PERSON PHONE 114 <br /> m � �r ❑ UNKNOWN (114 <br /> P.� <br /> . D l +cs ADDRESS <br /> I a GA G DRDa --b <br /> STREET CRY STATE ZIP <br /> FACE_FTY NAME(IF APPLICABLE) OPERATOR rl PHONE <br /> PQ CA-:&- Qcw <br /> ,` (gq) SM- ok97 <br /> ADDRESS <br /> DROSS STREET <br /> I ro rs1,, 5 <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON - PHONE <br /> STC P 1+5- e }-tom MGc.r NZ-I y-t o c )4b$-3M <br /> Gv 2vva PHONE } g <br /> m (1) NAME OUANTITY LOST(GALLONS) <br /> CRnUNKNOWN <br /> +n ❑ UNKNOWN <br /> DATE DISCOVERED pp'�� HOW DISCOVERS ❑ INV ORY CONTROL ❑ SUBSURFK&MON R NUISANCE CONDITIONS <br /> L21 �/ * e lJr Q r ❑ TANK TEST ❑ TANK REMOVAL OTHER�i P1 V% <br /> i DATE DISCHARGE BEGAN 416, <br /> METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK 8 REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 [::]REPAIR TANK <br /> 0 YES [-] NO YES,DATE O Q r r E]��CANK THTI�ACPROCEDURE <br /> ER _ <br /> SOURCE OF DISCHARGE Q CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE Cl SPILL <br /> ❑ PIPINGLEAK ❑ OTHER ❑ CORROSION �1NKNOWN ❑ OTHER <br /> t+m CHECK ONE ONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POSTCLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE IED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION{IT) <br /> qs rtas Pae cu.* <br /> ❑ CAP SITE(CD) ❑ EXCAVATE NI TREAT(ET) ❑ PUMP a TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REOUIRED(NA) ❑ TREATMENT AT HOOKUP(HLO ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) s�]OTHER(OT)�f;,I+C- ago <br /> Lu <br /> - KattA/tQ- eX4C/V Lei <br /> � Cam <br /> XSC os 16" <br />