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/�, <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES fOR LOCAL:AGENCTIUSE-ONLY <br /> ...... >:;::>:::`;;>..... <br /> ... ... ...... <br /> REPORT BEEN FILED 7 ............ <br /> FIYES NO 0 YES EL�J/NO HEREBY CERTIFYTHATI-HAVE DISTRIBUTED THIS wFoAmooki-AcconOING TO THE ..'*,.- <br /> DISTRIBUTION SHOWN ON:THE INSTjRUQT ET 0 BACK PAGE OF11-11S <br /> ...........................I...... ............ <br /> --. .. ......... ...... <br /> ...... ..... ........... ... <br /> REPORT DATE CASE# .... ......... ......... <br /> DATr <br /> O "SIGNED.::.;,:;;.. <br /> NAME OF INDIVIDUAL FILING REP RT PHONE SIGNATURE <br /> M V,OLa r'�+ <br /> ,>n 0 Dm q W-3 Lf <br /> fn <br /> REPRESENTING F-1 OWNERIOPERATVR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> Servi ct <br /> a yl J *v I on c eo- (411 <br /> LOCALAGENCYE] OTHER <br /> 0- ADDRESS <br /> STRUT CITY STATE ZIP <br /> w NAME CONT TPERSON PHONE <br /> z UNKNOWN <br /> rt <br /> wADDREP, 1 "J <br /> C_ <br /> < <br /> cr <br /> STREET CITY STATE ZIP <br /> FACILITY MME JIF APPLICABLE) OPERATOR PHONE <br /> z ;93S-330 <br /> 0 <br /> U ADDRESS <br /> 0 <br /> O <br /> w STREET CITY COU ZIP <br /> CROSS STREET <br /> 6 1 <br /> a LOCAL AGENqY AGEN� CONTACTPERSON PHONE <br /> z <br /> F-t.0 <br /> Z <br /> sa V <br /> LmLJ w REGIONAL 130ARD <br /> 0 u PHONE <br /> < <br /> UCL <br /> NAME QUANTITY LOST(GALLONS) <br /> UJ <br /> 0 W <br /> Z> ca) E&-C-NKNOWN <br /> 0 <br /> > <br /> z <br /> U) ❑ UNKNOWN <br /> z <br /> DATE DISCOVERED HOW DISCOVERED E] INVENTORY CONTROL F-� SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> w MI M i 6-1 1 o y1)-,1 ❑ <br /> TANK TEST 0 TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> 3;-- -19NKNOWN REPAIR PIPING REMOVE CONTENTS ❑CLOSE TANK REMOVE F <br /> tr <br /> UJI MI Ml DI DI Yl 11 EG- <br /> C, <br /> > HAS DISCHARGE BEEN STOPPED? E]REPAIR TANK ❑CLOSE TANK&FILL IN PLACE E]CHANGE PROCEDURE <br /> o 0 <br /> ED YES E] NO IFYES,DATE REPLACE TANK <br /> .1 .1 .1 yl y OTHER- INV-re*,-,oqe-cL 21D vx—rs <br /> ,-B SOURCE OF DISCHARGE CAUSE(S) <br /> F--] TANK LEAK �UNKNOWN F❑ OVERFILL r❑ RUPTURE/FAILURE ❑ SPILL <br /> 00 --1 OTHER F-1 CORROSION OTHER <br /> U) F--j PIPING LEAK UNKNOWN <br /> Lu CLw. CHECK ONE ONLY <br /> V) <br /> t�- <br /> 0 UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER Ej DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Z ❑ NO ACTION TAKEN <br /> PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> el� <br /> w j2 <br /> ir I <br /> cc LEAK BEING CONFIRMED F-] PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> L)rn F--j REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) E:] CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE DISPOSE(ED) E::] REMOVE FREE PRODUCT(FP) E:] ENHANCED BID DEGRADATION(IT) <br /> ISM BACK FOR DET, ) <br /> Z <br /> 50 E-1CAP SITE(CD) ❑ EXCAVATE&TREAT(0) ❑ PUMP TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w <br /> wCONTAINMENT BARRIER(CB) E] NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACTIVE) ❑ OTHER(OT) <br /> a w o V-le-'- f I a V\ ry 0 ,2-s� <br /> z <br /> OaA, +fve S Je- ko-5 bk2-ir— <br /> L (D <br /> HSC 05(&W <br />