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g c�3� <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED BE <br /> (LEAK)! CONTAMINATION SITE REPORT <br /> MEAGENCY HAS STATE OFFICE OF EMERGENCTHE <br /> Y SERVICES FOR LOCA(:AGr�iCY USE QN�Y` <br /> REPORT BEEN FILED? IH <br /> ❑YES ❑ DLSiRIBUT)ON SHOWN ON:THE INSTRUCTIONS SHEET ON��E aACK PACE OF THISOFORM_ <br /> O YES NO <br /> REPORT OA CASE r " DATE <br /> .r 1 SGNED - <br /> J w o ( d ( 1{ PHONE SIGNATURE <br /> c <br /> NAME OF WDIVIDUAyL FILING REPORT <br /> ❑ COMPANY OR AGENCY NAME <br /> REGIONAL BOARD <br /> � REPRESENTING ❑ OWNER/OPERATOR <br /> w <br /> LOCAL AGENCY ❑ OTHER c 6)'A CIA <br /> ADDRESS I T A L� �O�✓K J ST-9 nn��TrREET CONTACT NTACT PERSON PHONE <br /> UNKNOWN, <br /> �j <br /> mr �'4 <br /> O< -ADDRESS <br /> i �• i l..J C! �" �sTt�ET crs'i STATE <br /> I OPERATOR <br /> PHONE <br /> I FACILITYE Ps tx C <br /> Z V .-�e�� saw <br /> ADDRESS /1'), <br /> ) 1 we, <br /> f <br /> crry cmJ <br /> W ' <br /> N <br /> CROSS STREET <br /> (� <br /> NAME I CONTACT PERSON { yy <br /> PHONEG 2 c(� <br /> w SGLn LOCAL �CY AGENCY� �j <br /> z PHONE <br /> W <br /> w w REGIONAL BOARD r <br /> NAME OUANTRYLOST(GALLONS) <br /> UNKNOWN <br /> Q J <br /> m <br /> C:l UNKNOWN <br /> OATS DISCOVERED / Y HOW DISCOVERED Ll INVENTORY CONTROL. L J SUBSURFACE MONITORING i NUISANCE CONDITIONS <br /> z <br /> O i I ❑ TANK TEST 7— TANK REMOVAL OTHER 4 S <br /> a <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP OtSCHARGE(CHECK ALL THAT Y) <br /> UNKNOWN AEMOVE CONTENTS VEL CLOSE TANK a REMOVE U REPAIR PIPING <br /> Ell <br /> > HAS DISCHARGE BEEN STOPPED? <br /> no I J OI rI Y —1 REPAIR TANK `o❑_'1CLOSE <br /> TANK a FILL IN PLACE CHANGE PROCEDURE <br /> =REPLACE TANK OTHER©YES ❑ NO IF vE%DATE <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> a ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPIURElFAILURE SPILL <br /> m U a PIPING LEAK ❑ OTHER Q CORROSION UNKNOWN Q OTHER <br /> w w CHECK ONE ONLY <br /> N Q- <br /> v UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z iX I NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED Q POLLUTION CHARACTERIZATION <br /> w <br /> 2 <br /> � ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY POSTCLE/WUP MON(fORING Ui PfiOGFiESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(Ci.F.ANUP COMPL.=OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE a DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 810 DEGRADATION(LT) <br /> mm snot row uer.&M <br /> ao Oz ❑ CAP SITE(CD) 31 EXCAVATE a TREAT(ET) ❑ PUMP a TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Lu <br /> w a ❑ CONTAINMENT BARRIER(CS) ❑ NO ACTION REQUIRED(NA) (❑ TREATMENT AT HOOKUP NU) VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) c� - <br /> �L GZ4-de-a4-T7�P777 -LG r2 7-u2 cE'2c i <br /> f Gam' -L"(c _ems 7-� 4>1 <br /> l �Sc 05 I&W <br />