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17 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES AOR OC11[:'AGENCY <br /> p YEs REPORT BEEN FILED? 1 : <br /> ❑YEs ❑ No 1t( rT ►r�t�ivtslsra (�sa>Fotauno�tooru> to <br /> OHSTi( i(ON►SI(CN►NON(Tl TON7HE PM; QFTHNSFDRM <br /> REPORT GATE CASE i <br /> NAME OF�pID1VpUAL <br /> FLOG REPORT (� PHONE <br /> V SIGNATURE <br /> m (f � <br /> SENTING ❑ OWNERROPERATOR ❑ W14ALBOARD COMPANY OR AGENCY NAME <br /> S LOCAL AGENCY p OTHER <br /> a ADDRESS <br /> c o tumGjs'zd/ <br /> z NAME ODNT T PERSON PHONE <br /> "f/J1 y <br /> g ADDRESS (/ d��& <br /> � `� <br /> OfTY ATE —* <br /> 3-1 <br /> FACILITY NAME(F APPLICABLQ OPERATOR <br /> YAONE <br /> s'ArAAif..ADDRESS <br /> 3 J (�O '� nE — f? <br /> aCROSS STREET <br /> LOCAL AGENCY NAME CONTACT PERSON PHONE <br /> m <br /> PHS <br /> NAME QUANTITY LOST(GALLONS) <br /> p UNKNOWN <br /> i DATE DISCOVERED MOW DISCOVERED p Wyem"CONTRA ❑ ACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lu <br /> Vy TANK TEST p TANK REMOVAL � L ' l <br /> DATE OM>fARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> W C3UN KNOWN p REMOVE CONTENTS p NK CLOSE TA &REMOVE REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED Z ❑REPAIR TANK p CLOSE TANK a FILL N PLACE p CHANGE PROCEDURE <br /> p YES p NO IF YES.DATE j y y p REPLACE TANK ❑OTHER os <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> p PIPING LEAK OTHER p CORROSION UNKNOWN p OTHER <br /> u+Ly CHECK ONE ONLY <br /> UNDE)EAMINED p SOL ONLY p GROUNDWATER p ORNKING WATER-(CHECK ONLY IF WATER WELLS HAVE ACTUALLY SEEN AFFECTED) <br /> CHECK ONE ONLY <br /> M NO ACTION TAKEN p PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> im ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY p POST CLEANUP MONITORING N PROGRESS <br /> p REMEDIATION PLAN p CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> 04EC(APPROPRIATE ACTIONS) <br /> plt�raaRmu9 ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED SIO DEGRADATION(IT) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE i TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> p CONTAINMENT BARRIER(CS) p NO ACTION REQUIRED(NA) p TREATMENT AT HOOKUP(HU) p VENT SOX.(VS) <br /> ❑ <br /> VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> $�. � <br /> roc ► n�t -�-� o -� 2, <br /> t � <br /> �� r <br /> N8C C6(Mp <br />