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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES :FOFt,LOCAC?AGENCY USE ONLY, .--::::: <br /> REPORT BEEN FILED 7 <br /> ❑ YEs ( No 0 YES E] NO -- .. Y,CERFIFYTHAT)HA DISTRIBUTEDTHISINFORMATION ACCtlROiNGTOTHE <br /> REPORT DATE DISTRI8UT10N SHOWN ON TH STRUCTION ON THE 8ACK PAGE OF THIS FDRH! <br /> CASE a <br /> :�- <br /> <slc►ren <br /> NAME OF INDIVIDUAL FILING A ORT <br /> PHONE ' SIGNATUREEly <br /> Lu R PRESENTING ❑ OWNER/OPERATOR ❑ AEG BOARD COMPANY OR AGENCY NAME <br /> �f27 lk, <br /> LOCAL AGENCY ❑ OTHER D I <br /> ¢ ADDRESS <br /> i <br /> -- 'p. o Ala S72v�el�� <br /> Lu NAME Q CONT TPERSON PHONE Z1P <br /> co <br /> z� ❑ UN OWN r f. v\� <br /> a Q ADDRESS �� r <br /> y 5 -v v L vp orry <br /> w <br /> 42 <br /> FACILITY NAME(IF APPLICABL OPERATOR PHONE <br /> LS <br /> 2 '^ ✓'r 7t !', <br /> ADDRESS' <br /> �� <br /> J <br /> CITY <br /> 05 <br /> rP <br /> y CROSS STREET f4 o j �u <br /> W <br /> z LOCAL AGENCY AGENCY NAME CONTACT PERSON <br /> PHONE <br /> Lu <br /> LL,Cu REGIONAL BOARD /PHONE <br /> CL <br /> s f_ f /O�( /c - <br /> � f/�f t/ <br /> U (�) NAME OUAISITfry LOST GALLONS) <br /> ZLu <br /> UNKNOWN <br /> m z (2) <br /> D <br /> ❑ UNKNOWN <br /> Lu DATE DISCOVERED HOW DISCOVERED ❑ iNVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ -NUISANCE CONDITIONS <br /> I �� o oI h r ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP OQ,CHA (CHECK ALL THAT APPLY) <br /> w M o Y ❑ UNKNOWN ❑REMOVE CONTENT$ CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> oHAS DISCHARGE BEEN STOPPED 7 E:]REPAIR TANK ❑CLOSE TANK 3 FILL IN PLACE CHANGE PROCEDURE <br /> o ❑ YES ❑ NO IF YES.OATSul o v Y ❑REPLACE TANK ❑ OTHER <br /> w SOURCE OF DISCHARGE CAUSES) <br /> aa ❑ TANK LEAK NKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE SPILL <br /> w a PIPING LEAK OTHER OTHER <br /> ❑ ❑ CORROSION UNKNOWN ❑ <br /> y as CHECK ONE ONLY <br /> `� ❑ UNDETERMINED SOIL ONLY <br /> ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> } <br /> CHECK ONE ONLY <br /> z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED El POLLUTION CHARACTERIZATION { <br /> w <br /> Vw ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATEACTION(S) 1 <br /> a sSM QA"FOR oEr� C] EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) 666 <br /> o ❑ CAP SITE(CO} ❑ EXCAVATE&TREAT(ET) ❑ PUMP s TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Lu <br /> ¢ ❑ CONTAINMENT BARRIER(CB)Ix NO ACTION REOU[R£D(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> r - U4,-s�s r a ,� fi4 S <br /> U "fu ire, ac..� ���. �—_ c� v.,+ &47 c,�J <br /> � 1 lz e11 e � Ir e <br /> HSC 45{6'901 3 <br /> 3 <br />