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} <br /> II <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOp LOCAC AGEN USE ONLY <br /> REPORT BEEN FILED 4 1}{EREBY CERTIFYTHAT 1 HAVE DI-f4G TED THIS INFORMATION ACCOROING TOTHE. <br /> ❑ YES YNO ❑ YES ❑ NO <br /> DISTRIBUTION SHOWN ON THE INSTR TION SHE1 T ON BACK PAGE OF THIS FORM <br /> REPORT DAT£ r CASE 71 /�i.. <br /> GATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE 'I SIGNATURE <br /> . z SL c40 <br /> G -3 <br /> w REPRESENTING 'OWNER/OPERATOR ❑ REGidNALBoARo COMPANY OR AGENCY NAME <br /> ¢ LOCAL AGENCY ❑ OTHER �./�FI Q: IA{ <br /> ADDRESS 1) '/� y�o II ,(f//�,�{O� u~ <br /> f5 odh, <br /> A ATE <br /> J NAME J 'I {/fy� CONTACT PERSON ' PHONE { <br /> Q �{' C�� W� �j ❑ UNKNOWN <br /> z ✓ D <br /> CoQ ADDRESS <br /> ao' sTKA <br /> 6 <br /> FACILITY NAME(IF APPLICABLE) rte, OPERATOR PHONE d <br /> Z P LAS '1 v K-U[,I✓,fL L 1 b �J <br /> O <br /> ADDRESS �f yr D <br /> ° 1 J ✓ sraT' ► L l� Y cm covrrrr aP <br /> w <br /> ~ CROSS STREET <br /> �— T4 <br /> O LOGALAGENCY AGENCY NAME CONTACT PERSON PHONE �� <br /> _ iTJ{ Iqq <br /> -3 ir/2,G <br /> z U • J <br /> w w REGIONAL BOARD PHONE / <br /> 0 <br /> � {/V <br /> N (�) NAME QUA, ITY LOST(GALLONS) <br /> w <br /> ci r M <br /> (,NAME <br /> j _ ' ❑ UNKNOWN <br /> Q J <br /> F- <br /> m Z <br /> D <br /> j ❑ UNKNOWN <br /> = DATE DISCOVERED ;I HOW DIISCOVERED ❑ INVENTORY.CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> u oI yl ri. ❑ TANK TEST % TANK REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> ❑ UNKNOWN ❑REMOVE CONTENTS E:]CLOSE TANK b REMOVE ❑REPAIR PIPING <br /> w u o o r <br /> O HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK F]CLOSE TANK 5 FILL IN PLACE,E:]CHANGE PROCEDURE <br /> C3 ❑ YES ❑ NO 1FYES,DAT6 <br /> ml n r r [:],REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) V,] <br /> D ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE[FA1LURE E] SPILL i <br /> u0i O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> wwU)CL CHECK ONE ONLY Ilk <br /> UNDETERMINED �';❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> 2. <br /> CHECK ONE ONLY <br /> z ❑ NO ACTION TAKEN ;i ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> Oin <br /> ❑ REMEDIATION PLAN.t ❑ CAE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ;WE BACK Pon uerALM <br /> a ❑ CAP SITE(Cb) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP,S TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> O O <br /> Lu <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> Lu <br /> ¢ ❑ VACUUM EXTRACT(V5) ❑ OTHER(OT) <br /> m �Tf/�.a— `��U �c.�,... (/� CJS, �}• t�4� �j,�7 mow`✓`� <br /> 3 (f <br /> LLAn P ` o--�, <br /> 110 <br /> 40 ter► �h us 1 <br /> Hsc 0516'qq <br />