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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> 0 YES NO REPORT BEEN FILED 7 [::] YES 0 NO I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. <br /> REPORT DATE T CASE s <br /> O <br /> �M MI v C) V r SIGNED - DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> l_cn-t IrvtjcA-ej (207)` 4go33Gt���a <br /> REPRESENTING COMPANY OR AGENCY NAME <br /> w O OWNER/OPERATOR � REGIONAL BOARD <br /> LOCAL AGENCY a OTHER <br /> ADDRESS / , <br /> 30STREET t L�I� C(TY ,V STATE <br /> w NAME� ^ CONTACT PERSON PHONE <br /> Z OUNKNOWN r?:.rGTTL SAO"_soN <br /> ( ILS ) Lo l <br /> U Q <br /> CL a ADDRESS <br /> cc <br /> --/0 I STREETIA A- Sf if�O crry C St4b STATE Cl r IP I2' <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> S�T1-�Erz-Of-f__1� L GENrt ( ) <br /> ADDRESS <br /> L{Z <br /> w I♦ STREET 10 � L1 s _ ST-_ Cill' s r� /�/ COUNTYZI s 20 <br /> v-i CROSS STREET <br /> S t*-< al+ S.l� co -e It N o 2 1-- i2/u//i' <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> W SAiJ,:MAQUIti Co EnJV.He-n4 Lorz-1 <br /> wa REGIONAL BOARD PHONE <br /> m C n - IRI-C E`( Q_w dC 13 yv1'"t2-T�( I�Ar rZT�E(� M tk) ; �s <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> zLu YG I 1 -o UNKNOWN <br /> Q J <br /> m O (Z) <br /> UNKNOWN 0 <br /> Z /DATE DISCOVERED HOW DISCOVERED O INVENTORY CONTROL SUBSURFACE MONITORING a NUISANCE CONDITIONS <br /> w ll M M npl r 0 TANK TEST O TANK REMOVAL OTHER r <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Lu <br /> cr M D D r YJ <br /> UNKNOWN REMOVE CONTENTS CLOSE TANK 8 REMOVE REPAIR PIPING ,..� <br /> HAS DISCHARGE BEEN STOPPED? REPAIR TANK CLOSE TANK 8 FILL IN PLACE O CHANGE PROCEDURE <br /> U 'A <br /> U) <br /> � YES a M NO IF YES,DATE MI D 0 REPLACE TANK OTHER <br /> D V Y <br /> SO RCE OF DISCHARGE CAUSE(S) <br /> cn <br /> TANK LEAK UNKNOWN 71 OVERFILL RUPTURE/FAILURE SPILL <br /> cn v O PIPING LEAK OTHER CORROSION UNKNOWN O OTHER <br /> w w CHECK ONE ONLY <br /> N a <br /> U O UNDETERMINED SOIL ONLY GROUNDWATER D DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z NO ACTION TAKEN O PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED E�jPOLLUTION CHARACTERIZATION <br /> cr cc P O LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> U r7 REMEDIATION PLAN tj CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) 0 EXCAVATE&DISPOSE(ED) O REMOVE FREE PRODUCT(FP) E:] ENHANCED BIO DEGRADATION(IT) <br /> J (SEE BACK FOR UETA") <br /> aZFD O F-] CAP SITE(CD) EXCAVATE 8 TREAT(ET) PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> Lu Q CONTAINMENT BARRIER(CB) El <br /> NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) OTHER(OT) <br /> Z <br /> �U.� z w Lt,-( <br /> w <br /> 0 <br /> Q <br /> U <br /> HSC 06("o) <br />