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STORAGETANK UNAUTHORIZED (LEAK)/CONTAMINATION SITEREPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES (• � fNY USf ONLY <br /> 0 YES REPORT BEEN FILED? YES TfRI BY Q RT1F1'THAT E AM A D�SIGNAT (�GQV R.NM.i NT fMPGOYf ,AND F(. E I. <br /> .R t3 T#1TS.TNF. TTOAi TQ d(7CAL FIALS PURSUANT 70EGT[ # 180,3.i)F. <br /> REPORT DATE CASES ax <br /> THE <br /> M Y -1 Y .. T(:... .. <br /> .. ... <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> asp! aC� ( a9y - yl� Aovl, 4?r3l <br /> REPRESENTING Q OWNER/OPERATOR E REGIONAL BOARD COMT(pq AGENCY NAME r <br /> O 85 <br /> LOCALAGENCY ❑ OTHER /{�4Y <br /> w <br /> ¢ _ <br /> ARES •[ ® G2i� c�QUf/? 7� ng2C�(o <br /> `J9I SPREEf SPATE ZIP <br /> � NAME CONTACTPERSON PHONE <br /> FR A � UNKNOWN rou? r7ne_1 tyrs) 0 <br /> 99 co <br /> ADDRESS �� 70 �'j 5 <br /> wa <br /> STREET CITY SPATE 21P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADD SS <br /> /V� C �' uc� 572410 <br /> STREET CITY ZIP <br /> � CROSSS ET <br /> U) <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> rn <br /> z ( ) <br /> w� <br /> Lu" REGIONAL BOARD /PHONE <br /> 4fo <br /> l <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> 4 j UNKNOWN <br /> ° (a <br /> UNKNOWN <br /> w DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING F-1NUISANCECONDITIONS <br /> oM '2-ml ® /v / Y TANK TESTT REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BEGAN MET14M USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w` <br /> mi MI D1 DI Y1 yl UNKNOWN ® REMOVE TENTS REPLACE TANK CLOSETANK <br /> HAS DISCHARGE BEEN STOPPED 7 ® REPAIR TANK ❑ REPAIR PIING CHANGE PROCEDURE <br /> ® YES [—] NO IF YES,DATE ml M D1I yl Y x OTHER J&MOVa a// - K_S <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> Lu <br /> a TANK LEAK >�'UNKNOWN 0 OVERFILL E RUPTURE/FAILURE SPILL <br /> PIPING LEAK ❑ OTHER CORROSION UNKNOWN OTHER <br /> Lu w "04ECK ONE ONLY <br /> UNDETERMINED SOIL ONLY GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Q a `NO ACTION TAKEN 0 PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED Q POLLUTION CHARACTERIZATION <br /> cc <br /> cc N F__] .LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IJ PROGRESS <br /> O <br /> REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY \('� <br /> CHECK APPROPRIATE ACTION(S) ❑ 'EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) Ej ENHANCED BO DEGRADATION(IT) <br /> o F] CAP SITE(CD) � EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> Mu 5 0 CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) ❑ TREATMENTAT HOOKUP(HU) 0 VENT SOIL(VS) <br /> cc <br /> VACUUM EXTRACT(VE) a OTHER(OT) <br /> Lu <br /> ,� e a I rop tea_ <br />