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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES F LOCM AGENCY USE <br /> YES NO YES �NO ONi Y <br /> REPORT BEEN FILED 7 j HERESY CERTIFYTHAT. k.'A DISTRIHU D TH [S_INFOFIMATION'ACCORDING TOTHE< <br /> ' ❑ ❑ <br /> t plSTR 19U1'KJN SHOLVN DN THE(N$TRtJCTIDN SHEET.ON THE BACK RAGE OF THIS FORM: <br /> RE PORT DATE CASE M <br /> drQ v SIGNED ;[ GATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE Ij SIGNATU E <br /> m <br /> Lu REPRESENTING ❑ OWNERPOPERATOR E-1REGIONAL BOARD COMPANY OR AGENCY{NAM= <br /> °C OCAL AGENCY ❑ OTHER <br /> cADDRESS <br /> STATE ZIP <br /> Lu ME CONTACT PERSON PHONE <br /> I z G t t��-(LG ❑ UNKNOWN c ��o r <br />{ a a A <br /> Lo <br /> KESS l <br /> °� o _ l R <br /> T IT <br /> FACY NAME(IF APPLICABLE) OPERATOR `I /J /PHONE 4 <br /> Pio`[�►�— ` 51 7�{'ti7 Oil <br /> aADDRESS l+ ��H`�\c- / f_UA— C�0[.r ,1�4�urtfl Cl S p <br /> wD q D G~J . <br /> ~ CROSS STREET <br /> rn � , <br /> CONTACT PERSON PHONE <br /> LOCAL AGENCY AGENCY N77:� <br /> JUNKNOWN w :, PHONE <br /> ww REGIONAL BOARDaNAME �� pUANTITY LOST(GArn (�) ❑W 0wY Jm° ❑z JHOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING NUISANCEDATE DISCOVERED <br /> w TANK TEST TANK REMOVAL OTHER <br /> a 0 �� �� � b YI ❑ ❑ METHOD USED TO STfOP DISCHARGE(CHECK ALL THAT APPLY*IEPAIR <br /> C <br /> a DATE DISCHARGE BEGAN <br /> } 1NKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK b REMOVE PIPING w i M v v ❑REPAIR TANK' ❑CLOSE TANK 6 FILL IN PLACECHANGE PROCEDURE �A <br /> a HAS DISCHARGE BEEN STOPPED 7 <br /> c� REPLACE TANK ❑ OTHER <br /> ys DATE 3 <br /> o YES ❑ NO IF YE <br /> CAUSES) 'I <br /> SOURCE OF DISCHARGE A <br /> d TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURElFAILURE ❑ SPILL <br /> m l.3 <br /> { <br /> ❑� OTHER <br /> CORROSION ) <br /> I UNKNOWN ❑ <br /> a ❑ <br /> rp O ❑ PIPING LEAK THER <br /> ul w CHECKONEONLY �� <br /> rn m ❑ GROUNDWATER <br /> ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> cai UNDETERMINED SOIL ONLY ❑ <br /> CHECK ONE ONLY ❑ POLLUTION CHARACTERIZATION <br /> 1:1NO ACTON TAKEN <br /> z ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED <br /> z �! ❑ POST CLE/WUP MONITORING!N PROGRESS <br /> cc <br /> CH'— ❑ LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY I� <br /> O w ❑ REMEDIATION PLAN F-1 CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> REMOVE FREE PRODUCT(FP) ❑ ENHANCED BID DEGRADATION(ST) <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE b DISPOSE(ED) ❑ II <br /> {SEE 5WA Fin OETAL&) ❑ PUMP A TREAT,GROUNOWATER(GT)❑ REPLACE SUPPLY(RS) <br /> a z ❑ CAP SITE(CD) EXCAVATE&TREAT(ET) ❑ <br /> NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> wEs O ❑ <br /> F-1CONTAINMENTBARRIER(C8) <br /> cr ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) ' <br /> N � <br /> H <br /> Z <br /> W <br /> O <br /> u <br /> HSG RSWgq t <br /> I. } <br /> e <br />