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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> :F.PR. LOCA <br /> . . A:L AG:EN&. Vst-'-'ONLY NLY <br /> YES NO REPORTaE�NFILED7 YES IHERESYCEnFYrHAl <br /> HI <br /> ' "T <br /> . ..INq.T.0T <br /> ,OSTRtBUT10SHOWN:OWTHE'INSTRQp 9HE5rONTHEUCKPAGE0F:THI! . <br /> REPORTOATE <br /> CASE f <br /> -1 0 4 �<y SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE L-0SIGNATURE <br /> >- ml zeqbcdc,-3-5 afN-t��- <br /> bu A;CA/V ( ) <br /> ow REPRESENTING OWNERIOPERATOR 0 REGIONAL BOARD � COMPANY 0 q AGENCY NAME <br /> LOCAL AGENCY OTHER ;s 7,,4 1 VT—7 c> <br /> w <br /> cc ADDRESS <br /> 13 b STREET 0-1 wc-f5igz- CITY STATE F; <br /> NAME CO.NT.,ACTPl RSO <br /> tu X, p4po4,;�o PHONE <br /> r-�j L 7(L I <br /> 99 OSrATE-- OfL OiW i�V( !&PIC:]UNKNOWN ),33!;LilNl <br /> QO AOORESS <br /> u)EL <br /> w <br /> a: 'PO60)0 901; .11IF17 CITY STATE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS <br /> OJ ;tq too STREET s t 4AwYK(-,-r?-5. CITY T-rzA!LIY C.OUMY -5 ZIP 76 3 <br /> CROSS STREET <br /> t I -rk 's�) <br /> cry LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z'o <br /> z Lu eO. Lov?4 00"CAVA) (zot q6l?o 3 1 <br /> Lu 0 <br /> w w REGIONAL BOARD PHONE <br /> IL <br /> cl) (1) NAME QUANTITY LOST(GALLONS) <br /> w <br /> UNKNOWN <br /> j�>� (-I, <br /> C-D> (2) <br /> UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED <br /> Z INVENTORY CON IROL 0SUBSURFACE MONITORING E] NUISANCE CONDITIONS <br /> Lu <br /> m .1 .1 Di 0 TANK TEST TANK REMOVAL OTHER :�eopaV&!F <br /> Lu 0 9 2- I <br /> < DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> co <br /> "I <br /> .1 D D1 Yl 11 fo UNKNOWN E]REM VE CONTENTS W CLOSE TANK&REMOVE REPAIR PIPING <br /> 0 HAS DISCHARGE BEEN STOPPED? DREPA!R TANK E::]CLOSE TANK&FILL IN PLACE OCHANGE PROCEDURE <br /> a) 5YES E] NO IFYES,DATE . REP U 4E TANK OTHER 4 1 O� -3.1"' I ?YJ Y <br /> ,.a SOURCE OF DISCHARGE CAUSE(S) <br /> 0 0 F-1 TANK LEAK UNKNOWN 0OVERFILL RUPTURGJFAILURE SPILL <br /> cc <br /> 00 <br /> F-1 PIPING LEAK F--] OTHER 0 CORROSION � UNKNOWN E::] OTHER <br /> CHECK ONE ONLY <br /> DRINKII 4G WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> 0 UNDETERMINED E] SOIL ONLY GROUNDWATER F <br /> CHECK ONE ONLY <br /> z 0NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN UBMITTE:0 POLLUTION CHARACTERIZATION <br /> wp <br /> cr <br /> cc0 LEAK BEING CONFIRMED 0 PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UN t IECESSARY) 0CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) 0REMOVE FREE PRODUCT(FP) 0ENHANCED BID DEGRADATION(IT) <br /> (SEE BACK MR MAt.M <br /> 40 Z <br /> CAP SITE(CD) 0 EXCAVATE&TREAT(ET) 0 PUMP&TREAT GROUNDWATER(CIT)0 REPLACE SUPPLY(FIS) <br /> Lu <br /> CONTAINMENT BARRIER(CB) 0NO ACTION REQUIRED(NA) 0 TREATMENT ATHOOKUP(HUI) 0 VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) 0 OTHER(OT) <br /> fn <br /> Z <br /> 0 <br /> 0 <br /> HSC 05(w9c) <br />