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I .,.qq --ff u1 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCM AGENCY USE.ONIY <br /> REPORT BEEN FILED 9YES Eo'-'NOYES 0?"NO IHEREBY CERTIFYTHA71 HAVE DISTRIBUTED THIS INFOAMATIONACCORDINGTOTHE <br /> � <br /> IJISTR IBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS .ORM <br /> REPORT DATE CASE XiAJ <br /> OM (JM & V SIGNED <br /> NAME OF INDIVIDUAL FILING R PORT PHONE SIGNATURE <br /> m <br /> w REPRESENTIN 0 OWNERIYERATOR Q REGIONAL BOARD COMPANY`O_R^.AGENCY NAME i- _ <br /> cr �OCALAGENCY a OTHER ��� n <br /> 4w ri�O ��� �tO`ollC' �� Ig an CC'S <br /> cr ADDRESS <br /> L4 y s 1q, Say" r r 6+6 c�C-f t o Clf+ <br /> r, STREET//1,, i j GTV Q STATE ZIP <br /> QOWN <br /> Z NAME We-j+'z'cr) P-e7 ' t LJ��1A`-� �NICON t IEbO� PHONE ) <br /> a <br /> ad ADDRESS <br /> w P.0 Box L 5 3 b S Lta r� �S SCI S-,5�6.s <br /> STREET CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> z r a Ca <br /> 0 <br /> U ADDRESS ^^ c-P _ (/_ �, �rQ <br /> (� I �a �-{-(-J'v�lJlf -5 A*'-io a z"r r, 9 53 7!6 <br /> W STREET CITY COU ZIP <br /> )- CROSS STREET <br /> m <br /> �e Ve r-{- <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> W ,n Go Pulol��{(ea I -h u r v (•`+�9 ) �6�35/�l <br /> Z5 <br /> U <br /> w w REGI NAL BO RD PHONE <br /> U) (t) NAME QUANTITY LOST(GALLONS) <br /> W <br /> ZW was© � ►� e <br /> a J UNKNOWN <br /> m (2) <br /> z <br /> U) <br /> UNKNOWN <br /> DATE <br /> DISCOVERED HOWDISCOVERED <br /> INVENTORY <br /> yqNTROL RFAMONITORING INJSAN�sCONm IONS <br /> mOMI qMI 0-14DI Y Y TANKTEST TANK REMOVAL t�7 �r <br /> m <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN REMOVE CONTENTS a CLOSE TANK&REMOVE REPAIR PIPING <br /> w M M O D Y Y <br /> O HAS DISCHARGE BEEN STOPPED 7 REPAIR TANK 0 CLOSE TANK&FILL IN PLACE CHANGE PROCEDURE <br /> U) YES 0 NO IF YES,DATE I �REPLACE TANK (OTHER ���&jkA4;, VV !fn r2(d.5 <br /> U % M M D D V Y Yom_ <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> W <br /> j {�� <br /> 2 O ?' <br /> TANK LEAK F; UNKNOWN 0 OVERFILL F-1 RUPTURE/FAILURE SPILL <br /> C v 0 PIPING LEAK F--� OTHER 0 CORROSION UNKNOWN OTHER <br /> Lu w CHECK ONE ONLY <br /> U UNDETERMINED 0 SOIL ONLY E::] GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wcc <br /> 0 NO ACTION TAKEN a PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> cc I- O LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY 0 POST CLEANUP MONITORING IN PROGRESS <br /> U a REMEDIATION PLAN a CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) 0 CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) 0 EXCAVATE&DISPOSE(ED) a REMOVE FREE PRODUCT(FP) O ENHANCED BIO DEGRADATION(IT) <br /> J (SEE BACK FOR MALS) <br /> o O O CAP SITE(CD) Q EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT)0 REPLACE SUPPLY(RS) <br /> w� <br /> w a a CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) E::] VENT SOIL(VS) <br /> 0 VACUUM EXTRACT(VE) OTHER(OT) <br /> z <br /> uj <br /> 0 <br /> O <br /> U <br /> HSC 05(MO) <br />