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TAir) -6)/ Iv <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL'AGENCY.USE ONLY <br /> ❑ YES NO REPORT SEEN FILED? E] YES <br /> Pio <br /> ❑ j}IERE6YCERTIFYTHAT{HAVE_DISTRGUTEDTHISINFORMATIOi(ACCORDINGTOTHE_ <br /> ;.p1STFi 19UTIDN SHOWN ON SHEE:C ON'THE SACK PAGE OFTHCS FOR <br /> REPORT DATE �y 9 CASE N <br /> Dwsl DATE....,.; - <br /> NAME OF INDIVIDUAL.FILING REPORT PHONE SIGNATURE <br /> Br r e Q61)Xh6g-31fv <br /> w REPRESENTING ❑ OWNER/OP T R Q REGIONAL BDARD COMPANY R AGENCY NA H Iti <br /> LOCAL AGENCY Q OTHER CV[CJ+' S J <br /> R <br /> Lu <br /> cc ADDLE o Oa x S 8' �`�`o�f�� C�4 . 4 S A,6 -037r8' <br /> I}� STREET CRY STATE ZIP <br /> J NAME /� �1� r CONTACT PERSON PHONE Q" / C� <br /> z c&AG f C/fe 1[ C . Q UNKNOWN �� Ip/ q D 3 ^(QcJ <br /> ADDRESS <br /> r1 ( <br /> a i ! <br /> STREET CITY STATE ziP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> Z ^ter <br /> a <br /> .c ADDRESS <br /> w RE CITY HTV ZLP <br /> y CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z Q s�, P f4s - v r s tai <br /> w w REGIONAL 130ARD jj PHONE <br /> a a KJ G -f—� <br /> N li) V1� NAME QUANTITY LOST(GALLONS) <br /> w <br /> Lu Z ❑ <br /> a J UNKNOWN <br /> m z (� <br /> ai UNKNOWN <br /> zALJ <br /> DATE DISCOVERED HOW COVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Did —sr T 4d o / r ❑ TANK TEST TANK REMOVAL OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPL <br /> w o o Y Y <br /> UNKNOWN ❑REMOVE CONTENTS CLOSE TANK A REMOVE ❑REPAIR PIPING <br /> u <br /> HAS DISC,HEASRGE BEEN NO T F YESDATE/ J ❑REPLACE TANK REPAIR TANK ❑ OTHER TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> O VM -� 1 �,, `f[::] Y ❑ ❑ <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> W <br /> TANK LEAK ❑ UNKNOWN OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> a <br /> 'n L) 0 <br /> PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> N 4 <br /> v� UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ 'DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> cc <br /> = ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SFTE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> U rn ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT{FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> a Z Is�eKx wnoenust . <br /> 60 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(" ❑ PUMPS TREAT GROUNDWATER(GT)E:] REPLACE SUPPLY{RS) <br /> tij <br /> w c ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REOUIRED{ ) ❑ TREATMENT AT HOOKUP(H11} ❑ VENT SOIL(VS) <br /> ❑ <br /> VACUUM EXTRACT(VE) OTHER(OT) - _�se �7 v) <br /> z <br /> Lu <br /> L�� ST`s cz <br /> 05WOO <br />