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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR(OCAL'AGENCY USE ONLY <br /> ❑ YES F-1 No REPORT BEEN FILED? 0 YES ❑ NO 144EREBY CERIIFYTHAT I HAVE DISTRIBUTEDTHIS9NFORMATION ACCDADINGT07HE <br /> aEPoaroatE - DISTRIBUTIONSHOWNONTHEWSTRUCip"HE ETONTHEBACKPAGBOFTNISF-ORM <br /> �7 CASE <br /> OM •M �. 1.- D / If <br /> Y SIGNED DATE: <br /> NAME OF INDIVIDUAL FIUNGEPO T PHONE SIGNATURE <br /> rI v (�v; ) l(08-3 yY9 <br /> O COMPANY <br /> REPRESENTING <br /> ❑. OWNEFVOPERATOR ❑ REGIONAL BOARD ORAGENCYNAME <br /> SLOCALAGENCY ❑ OTHER <br /> w <br /> ¢ AbDFIFSS <br /> ,,S,T�RpEEY __...._ .._____-_ _. CITY- _ srATE <br /> NAME air <br /> - ��TI'y.J /0. CONTACT^ PERSON PHONE <br /> E5 a R( kIC/ ` AA. UNKNOWN t-%��_ 4.. ) <br /> R d ADDRESS <br /> w 3 9 0o,�.t¢. <br /> oo , <br /> FACILITY NAME{IF APPLICABLE) - cirr STATE <br /> OPERATOR PHONE <br /> Z <br /> ADDRESS � ( ) <br /> bx- <br /> r _ STREET .. CrtY '' w <br /> y CROSSSTREET <br /> �umR <br /> i w LOCAL <br /> "yAG�ENCY' AGENCY NAIAD CONTACTPERSON PHONE <br /> Jw �RE+G�IONAL�B�OARD ,/ I �� ( ) ���✓T <br /> ¢ / A IIX.v� t"v 80 PHONE <br /> m 01 _ NAME QUANTITY LOST(GALLONS) <br /> ¢> V <br /> m Z R) UNKNOWN <br /> NKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Y Y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> ¢ DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M o o Y Y UNKNOWN REMOVE CONTENTS LOSE TANK&REMOVE ❑REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED 7 1 ❑REPAIR TANK ❑CLOSE TANK 8 FILL IN PLACE ❑CHANGE PROCEDURE <br /> pVES ❑ NO IF VES,DATE QM 4M SD V -7Y ❑REPLACE TANK ❑ OTHER <br /> �w OURCE OF DISCHARGE CAUSEIS) <br /> 2� ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURHFAILURE ❑ SPILL <br /> y0 ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w CHECK ONE ONLY <br /> O ❑ UNDETERMINED ❑. SOIL ONLY t213 GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ¢� ❑ NO ACTION TAKEN ❑ PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> jN LEAK.BEING CONFIRMED ❑ PRELIMINARYSITE ASSESSMENT UNDERWAY ❑ POSTCLEANUP MONITORING IN PROGRESS <br /> U <br /> REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) O EXCAVATE B DISPOSE(ED) ❑ REMOVE FREE PRODUCT(PP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> pss ewac rov o�*usl <br /> 0 0 ❑ CAP SITE(CD) ❑ EXCAVATE 8 TREAT(ET) PUMP 8 TREAT GROUNDWATER G <br /> w�_ ❑ ( T)❑ REPLACE SUPPLY(RS) <br /> i ❑ CONTAINMENT BARRIER(CS) ❑ NO ACTION REQUIRED ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) 14 OTHER(OT) ✓e. <br /> r <br /> Z <br /> w <br /> f <br /> U <br />