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"Ar.ENCY [::] <br /> RGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY - <br /> REPORTSEENFILEDY ND I HEREBY CERTIFYTHATI HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> NO ❑ YES DISTRIBUTION SHOWN ON TH�UC N SHEET ON THE BACK PAGE OFTHIS FOOR14CASE A � - IT-d SGNED DATE <br /> INDIVIDUALFIUNG REPORT . PHONE SIGNATURE <br /> r area" L ria (�c�i )4l2-3L((fR 7��❑ REGIONAL BOARD COMPANYOENTI OWNE PERATOR 0.❑ SbIL4 OCALAGENCY ❑ OTHER U UIY'On o-n <br /> 8 <br /> a ADDRESS L.' �C� IV ' SA�Y� �1.1Y✓�. J'�oLh- Q S,zkOy <br /> STREET U cT RATE ZIP <br /> NAME l, CONTACT PERSOON /PHONES <br /> �a UNKNOWN J0�� �T�fb�.2�I I� <br /> m� <br /> zIE <br /> a ADDRESS ( S ��` � Sa( <br /> V <br /> I o2I� CST E� ( �j7(J`m "'�Y� STATE ZIP ("� <br /> FA <br /> TY NAME(IF APPLICABLE) n ' OPERATOR PHONE <br /> bol 7evarc� �t ornc� t Ge <br /> SS (^ � .�1 \ STfiEET crtY cWHTY ZIPS STREET <br /> F -a <br /> LOCAL AGEj CY �.A.��,� A N Y AME CONTACTPERSON PHONE <br /> �m ✓l u I n CDuvY, a �L` Hea i-4� r 10 (,WA) b8 3 L{9 <br /> =o erutc ronin Q <br /> w E REGIONAL BOARD PHONE <br /> c.v P,LA) 0.c-8 SSS 3133 <br /> ur ()) NAME QUANTITY LOST(GALLONS) <br /> Q 0 ���I I �Q_ �/GNKNOWN <br /> Z> <br /> a � <br /> w ❑ <br /> UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> z <br /> w <br /> O w IM V o 3 Ui S2Yj-5r ❑ TANK TEST �ANK REMOVAL O OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> �NKNOWN ❑REMOVE CONTENTS CLOSE TANK a REMOVE REPAIR PIPING <br /> w M 0Yi <br /> >O HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK CLOSE TANK 8 FILL IN PLACE =CHANGE PROCEDURE <br /> o YES a NO IF YES,DATE OMI q.1 ODI 3 3yl 5/ ❑REPLACE TANK ❑OTHER <br /> w SOURCE OF DISCHARGE CA <br /> DSE(S) <br /> F7 TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> ti O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> ww CHECK ONE ONLY <br /> Q dUNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER [:] DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w� dNO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> my LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> 0 ❑ REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE d DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(1T) <br /> ICAau RA <br /> <z ❑ CAP SITE(CO)O) <br /> ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP d TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ¢ ❑ VACUUM EXTRACT(VE) ❑ OTHER(On <br /> SLt2_ ti.as bz�� PI.aLe 1oc,<l �e2tv�a�e�I 5ii-� da�bnsc <br /> mru r+Kea-' i n u e_s 0, \ a v. re- e- L a:6 o-, w , t l b,2-- <br /> 0 e0 <br />