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`w Cl/-L,(-7 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERG NCY SERVICES .-FOR LOCALAGENCY.USE ONLY: <br /> ❑ NO REPORT BEEN FILED T YES Q NO ::HERE8Y CERT)FY THAT t AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT S HAVE <br /> YES <br /> LL��JJ ,REPORTED.:TH(S!NFORMAT)ON;TO LOCAL;QFFIC(ALS:PURSUANT TO SECTION 2518Q7 OF; <br /> REPORTD,ATE CASES THE HEALTHAFTY <br /> `^ E � <br /> OMI ( MI 2d D Y1 I Y <br /> oaT•--E� <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> 0 REPRESENTING ❑ OWNERIOPERATOR REGIONAL BOARD COMPANY OR AGENCY NNAME <br /> O i v LOCAL AGENCY E:] OTHER y D <br /> w <br /> ADDRESS nn J, f - /' Q <br /> .0. a LY ��1�M STREET S ��UN cry C/4. STATE ! 52Q 1 ZIP <br /> w NAME CONTACTPERSON PHONE <br /> J / u <br /> F 2 A O CC a� ❑ UNKNOWN (,i �/ u �� ) <br /> co a ADDRESS / 1 1 J <br /> .o �tK f t o STREET -/�/L-/�/j erry STATE 5:;L Q/ ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ) <br /> ADDRESS <br /> 413 b S 61 �o ST' c T 94- crrY ScxN (i x� Zf/N ..Ty S.2�� P <br /> J <br /> ti CROSS STREET <br /> a-kIN/p <br /> a LOCALAGENCY AGENCY NAME OONTACTPERSON PHONE <br /> 9 y <br /> W S' ryS-EHb �c9 ) Yds - .to <br /> REGIONAL BOARD PHONE <br /> w (1) NAME QUANTITY LOST(GALL S) <br /> auj <br /> 0 / <br /> O I�(,{/h� p(' GENS UNKNOWN <br /> U-O <br /> co <br /> ?Z (7) <br /> N <br /> ❑ UNKNOWN <br /> w GATE DISCOVERED HOW DISCOVERED j INVENTORY CONTROL ❑ SUBSURFACE MONITORING E] NUISANCE CONDITIONS <br /> 2' M M /�.D D Y y ❑ TANK TEST TANK REMOVAL OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M D D Y yl Eg/UNKNOWN REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> 0 HAS DISCHARGE BEEN STOPPED 1 ❑ REPAIR TANK REPAIRPIPING <br /> ❑ CHANGE PROCEDURE <br /> o YES ❑ NO IF YES,DATE 0.1 6 M O DI 6 D1 YIy OTHER ���S /Qr1yJ?c>u•'�/[ <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> a ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFLL ❑ RUPTURE/FAILURE SPILL <br /> ���777SSS v PIPING LEAK ❑ OTHER ❑ CORROSION r UNKNOWN OTHER <br /> Lu U)a CHECK ONE ONLY <br /> v ❑ UNDETERMINED a SOIL ONLY a GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ZN <br /> w� ❑ NO ACTION TAKEN � PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> v91 ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING W PROGRESS <br /> Q REMEDIATION PLAN a CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) E::] CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> Igee�c�PaaoerAa� EXCAVATE&DISPOSE(ED) <br /> REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> oz <br /> 0 4 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP d TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> 2 a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) \ <br /> VACUUM EXTRACT(VE) OTHER(OT) <br /> 411 Gf¢sT"s L►uvc IoPFN 1 Amo <br /> Z <br /> Lulrs <br /> 'a�tr_�rr� /o�•�•lysis ls�i.�y , �'rLs��y o'.,�.•ir� hrP,� rCr�, <br /> U Ntr/�/T�f/�• /7I rn O"'� '� Z. C'e�../R 7'�/re:u�/ S'. LZ' S']Fic 1�S� O.-e'� o��rl��^�a�f Gin.�rt�S <br /> Si Z` <br /> ' HScoslii/m <br />