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UNDERGROUND STORAGE TANK UNAUTHORIZED ,P (LEAK) <br /> �I <br /> RELEASE LEAK 1 CONTAMINATION SITE REPORT � <br /> EMERGENCY HAS STATE OFFICE OF EMER ENCY SERVICES FOR.lOCAL'AGENCYV$E ONLY. <br /> ❑ YES NO I� REPORT BEEN FLED 7 [ YES NO 1 HEREBY CER7IFYTHAT 1,HAVE DISTRIBUTED THIS INFORMATION ACCOfaDING TOTHE <br /> [;?YES plStAl TfONSHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM i <br /> REPORT DATE CASE a- <br /> 0.1 3.1 / a 6 a 96NEb` :DATE <br /> ... .. .: .: 1111 ' <br /> . . . 11::11 <br /> NAME OF INDIVIDUAL FILING REPORT PHONE tl SIGNATURE <br /> m <br /> rks i' rN (2oq ) 4168-3Yyd <br /> Lu REPRES NTING Ej OWNERlOPERATOR F-1REGIONAL BOARD COMPANY OR AGENCY NAME <br /> cr <br /> 2 LOCAL AGENCY ❑ OTHERLu <br /> I <br /> ADDRESS I r <br /> Cm .. STATE <br /> Lu NAME CONTACTPERSON PHONEca 4 <br /> i <br /> J <br /> z Ir UNKNOWN r f K CI ) �•T `�OG0 <br /> a¢ ADDRESS 'I <br /> �d f <br /> STREET Sfal'kl+OP•I 4 CITY �I I. STATE 9- +Lu} p <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> s" { Pr->rr�r,, 7rvc� a. s Stc> s� (zo9) 06%V <br /> I <br /> a ADDRESS ? ( 4 <br /> Lu STRCITY covw Y zip j <br /> �= CROSS STREET <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> I. ) <br /> zW <br /> w w REGIONAL BOARD PHONE <br /> I. <br /> rn (7) p �I NAME QUANTITY LOST(GALL NS)WC ' <br /> ar <br /> a !'7 I•, SC.�-I UNKNOWN <br /> NO <br /> j2 } `V <br /> UNKNOWN <br /> I- DATE DISCOVERED HOW DISCOVERED ❑ NVENTORY CONTROL- ❑ SUBSURFACE MONITORING ❑ NUESANCE CONDITIONS <br /> w � o a Yi Zr ❑ TANK TEST TANK REMOVAL ❑ OTHER i <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHA E(CHECK ALL THAT APPLY) t '! <br /> UNKNOWN ?I REMOVE CONTENTS CLOSE TANK 6�REMOVE ❑REPAIR PIPING VV <br /> p HAS DIS ARGE BEEN STOPPED? ; {:, REPAIR TANK CLOSE TANK 6 FILL IN PLACE ❑CHANGE PROCEDURE <br /> 2IJ ES ❑ NO .',[F YES,DATE M 2 !D Y ! REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE!,! CAUSE(S) <br /> Lu <br /> cc`; ❑ TANK LEAK 2(UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE:❑ SPILL <br /> O ❑ PIPING LEAK ❑ OTHER CORROSION UNKNOWN ❑ OTHER <br /> Lu a CHECK ONE ONLY <br /> ai <br /> UUNDETERMINED" ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) ' <br /> CHECK ONE ONLY 6 <br /> ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION-CHARACTERIZATION F <br /> P ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED bR UNNECESSARY) ❑ CLEANjP UNDERWAY jI <br /> F <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 6 DISPOSE(ED) i3 ❑ REMOVE FREE PRODUCT(FP) ENHANCED 810 DEGRADATION(M <br /> C399IaCK FOR OUALM <br /> o p ❑ CAP SITE(CD) ;, EXCAVATE 6 TREAT(ET) ,` PUMP a TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> uj <br /> a CONTAINMENT BARRIER(CB) F—] NO ACTK)N REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) i <br /> Z �'TYII-' x//l/'T d�� <br /> 'A �• ,3' �j�/bc✓i� -�ixc ld/r?a» c9 IPSP/ ��k, i� �p 6Sf C•pn,��•va�c% Siaft /Ljl�F �� � <br /> I <br /> HSC CSI5" <br />