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' � U► V <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES ._FOR LOCAL AGENCY USE ONLY <br /> YES NO ❑ NO <br /> REPORT BEEN FILED ? 1 HEREBY CERTIFYTHATI HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ VES <br /> . ,DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON RHE BACK PAGE OF THIS FORM <br /> REPORTDATE xN (7�(� CASE ♦ - <br /> VM M V V Y SIGNED DATE <br /> NAME OF INDIVIDUAL FILIN�AEPOR_L � � � PHONE � � J � SIGNATURE <br /> REPRES NTING ❑ OWNER/OPERA R ❑ REGIONALBOARD COMPANY OR AG NCY NAME <br /> L <br /> OCAL AGENCYY ❑ OTHER <br /> ADDRESS O G�.e, S'f ,3 "� -�loar -S� <br /> 3tow4e)-i /4 <br /> ST.S BEET cm STATE ZIP <br /> NAME CO ACT PERSON PHONE �t <br /> wCAL I I ❑ UNKNOWN ' Q � J 7 <br /> Q < ADDRES <br /> poor isdIxSf c /cl v C�d� 9 0� <br /> FACILITY NAME (IF APPLICABLE) OPERATOR PHONE <br /> 02 ADDRESS ll a <br /> w0 F <br /> arREEr cm couNry nR <br /> y CROSSSTREET � �Sfre,� <br /> i LOCALAGENCYYj� AGENCY NAME CONTACT PERSON PHONE <br /> w w REGIONAL BOARD PHONE <br /> � O <br /> R U) G C3 c <br /> m0 <br /> (1) NAME QUANTITY LOST (GALLONS) <br /> oUNKNOWN <br /> i (2) <br /> ❑ UNKNOWN <br /> r <br /> DATE DISCOVERED /�J� J((y HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> " Mj ! M / o DI / x ✓ v ❑ TANK TEST ❑ TANK REMOVAL0>5LOTHEq zz�it glonu Ls <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> `cM M o o r r UNKNOWN REMOVE CONTENTS LOSE TANK & REMOVE ❑ REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIR TANK "`❑ CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE <br /> 5 YES ❑ NO IF YES, DATED ( (,l �p I Y v r E] REPLACE TANK ❑ OTHER <br /> tD w4SOLIRCI OF DISCHARGE CAUSE(S) <br /> j ❑ TANK LEAK UNKNOWN ❑ OVERFILL ,❑ RUPTURE/FAILURE E] SPILL <br /> wO F-1PIPINGLEAK F-] OTHER ❑ CORROSION IXI UNKNOWN ❑ OTHER <br /> ww CHECKONEONLY f� <br /> >9�4NDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w � ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ¢ � ><LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O w ❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br /> I�€SM* rwoe.Assl <br /> az <br /> a0 F-1CAP SITE (CD) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & ,TREAT GROUNDWATER (GT) REPLACE SUPPLY IRS) <br /> w ❑ CONTAINMENT BARRIER ICE) ❑ NO ACTION REQUIRED (NA) ❑ TREA^TM}E,NT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br /> ❑ VACUUM EXTRACT (VE) IF< OTHER (OT)�Lj <br /> W, ez.g <br /> 7? a�zv X 7mP <br /> Q <br /> 4 <br /> HSC 0J"D). <br />