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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(L GQt>rT IN SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICESFOR LOCAL AGENCY II.RE`�' � <br /> ❑ REPORT BEEN FLED <br /> YES 9 ❑YES �} NO <br /> )HI'CY7liAT}11]NIEpSTR6t�tT10FtAliDNIGTO�fIE <br /> REPORT DATE CASE r �Jr PAI;E OFFM� <br /> 3 <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> > (Si4 )g�tz 6 S <br /> m <br /> REPRESENTING OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> ¢ ED OTHER CifEYRpN (�$�- 2v/�dLtS C/�o""P Y <br /> S <br /> � <br /> ADDRESS <br /> a1jo CRM,.Vo RuAl S,4.NP.W1 ,.A/, c•4 4 83 <br /> STRECT CRY STATE ZIP <br /> w <br /> NAMECONTACTPERSON PHONE <br /> oemeogiw Q . Co. ❑uNKNowN _ _ Jit i (5/C ) 216 S <br /> �a <br /> ADDRESS p D-BjDX 5Q0 A� Si4N R O VV AL) �'� `jrf5��-N?�Z/ <br /> sT�etT cRr / STATE <br /> FACLITY NAME(IF APPLICABLE) OPERATOR I PHONE <br /> 's C �/ CHS✓ �o, (�9 )333 / D <br /> t ADDRESS <br /> 2,S�S0 ffwY 99, l✓oxr�+ ff AMPO S� ✓ID g?,V/ <br /> Lu <br /> STREIT <br /> ZIP <br /> ti CROSS STREET <br /> ¢ LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> W Sir jC.4jaV1lV Cil ry tK#owjw Sls . T,z,c✓,E„/ <br /> REGIONAL BOARD PHONE <br /> CENZIML icy <br /> co (I) NAME OUANTTTY LOST(GALLONS) <br /> Lu E;JdlNh Cff Ui✓ UNKNOWN <br /> m ❑ UNKNOWN <br /> = DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> ' ❑ TAMC TEST N2 TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE tCHECK ALL THAT APPLY) <br /> ®REMOVE CONTENTS ®CLOSE TAMC i FEMOVE ❑REPAIR PIPING <br /> HAS DISGIAP40E BEEN STOPPED T +`—•' ❑REPAIR TANK ❑CLOSE TANK i FILL IN PLACE ❑CHANGE PROCEDURE <br /> g I YES ❑ NO IF YES OATS Y Y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE <br /> j TANK LEAK C:] UNIQNOWN OVERFILL ❑ RUPTURE/FALURE ❑ SPILL W <br /> U <br /> PIPING LEAK ❑ OTHER ❑ CORROSION � INHQJOWN ❑ OTHER <br /> w ow. CHECK ONE ONLY <br /> ❑ UNDETERMINED SOL ONLY ❑ GROUNDWATER ❑ DRINKING WATER-#>IECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) �\ <br /> CHECK ONE ONLY V( _ <br /> Z 0 ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED Q POLLUTION CHARACTERIZATION l <br /> ¢q ❑ LEAK BEING COWRMED 50 PRELIMINARY SITE ASSESSMENTUNDERWAY Q PoSTCXEANUPMONFTORIKiWPROGRESS <br /> O Q REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&OISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) Q ENHANCED BIO DEGRADATION(Il) <br /> Las Mac ro+aRwal <br /> Q CAP SITE(CD) r7 EXCAVATE&TREAT(ET) Q PUMP i TREAT CifoUNOWATER(CTT)❑ REPLACE SUPPLY(R5) <br /> No ❑ CONTAINMENT BARRIER(C.8) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP No ❑ VENT SOL(VS) <br /> ❑ VACUUM EXTRACT(VE) Q OTHER(07) <br /> 2 <br /> w FvRr�ej�0_ /N✓4:--S TlG,fTi0N 4/1 cL PRocC-E-d vP V 44�41Y7,lo1Cr <br /> R ✓ITS rROM Tirutt t2�MO✓rFt SAM/'c!Nl. <br /> cucastaiw <br />