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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STAT OFFICE OF EMERGENCY SERVCZS FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED <br /> _I YES YES No <br /> HE'RSY.CSFMFYTHAT}HAVE DISTRIBUTEDT IIS INFORMATICNACCCROING TO THE <br /> NO ❑ ❑ <br /> .:.6l5M66CN CN. lNSTRjDCMRSHEci.CN7HE PAGcOF:THISFCAAI::: <br /> REPORTTyDATE 9 CASE, L <br /> SrSNED RATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGN <br /> yW <br /> REPRES TING ❑ c ❑ REGIONAL 30ARO aMPANY R AGENCY NAME , <br /> OWNERIOP_RATOR <br /> 7OCAL AGENCY ❑ OTHER `/�O 64N <br /> ADDRESS <br /> /"?o, /3 J-,1 �9R S �o,✓ �A� 9S2Oi <br /> wAMME CONTACT PERSON PHONE Q� <br /> `7i UNKNOWN <br /> a ADDRESS <br /> wLu <br /> a <br /> c (�QsmeFr /VI4V LJ/G1 crrr �7;n'V sr-Te <br /> 'AC11TY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS <br /> 20o S <br /> 4TREET (�/� CTr COUMy S�T� -lip <br /> a CROSS STREET <br /> LLE ,ervE <br /> LOCAL AGENCY AGENCY.VME CONTACT PERSON PHONE <br /> = A/ 7TO <br /> w w REGIONAL BCARb PHONE <br /> <, Cil/ Gly .B D 6-x-5 �• I /lo I- � <br /> y (t) NAME OUANTTTY LOST( <br /> 4 <br /> v '� /O G z3 LE1vc <br /> U <br /> �J UNKNOWN <br /> O <br /> Z m /3 3 PC Bs UNKNOWN <br /> l - OA.c DISCOVERED HOW DISCOVERED ❑ fNVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Z <br /> r ❑ TANK T^cST ❑ TANK REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BEGAN MEi1I00 USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> y w <br /> oNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK a REMOVE ❑REPAIR PIPING <br /> HAS OISC14ASGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL N PLACE ❑CHANGE PROCEDURE <br /> a ❑ YES ❑ NO ,FYES,DATEuI u d <br /> C:]REPLACE TANK C:] OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> LJ TANK LEAK �NKNOWN ❑ OVEAFiLL �❑ a RFJFAILURE ❑ SPILL <br /> U)v ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w w CHECK O NLY <br /> Na <br /> U UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ ORINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CH;; NOACTION <br /> NLY <br /> y TAKEN ❑ PRELIMINARY SITE ASSESSMENTWORKPl1W SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING W PROGRESS <br /> 0 y <br /> v ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATES DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 810 DEGRADATION((T) <br /> J IS@ b.GR FW OETAIII� <br /> Oo ❑ CAP SITE(CO) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w <br /> CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> I <br /> A 7 <br /> w <br /> f <br /> J <br /> MSC aS 4&W <br />