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EMERGENCY HAS STATE OFFICEOF* • • <br />F --j <br />YES >1 NO REPORT BEEN FILED ? YES <br />NO <br />REPORT DATE <br />NAME OF INDIVIDUAL FILING REPORT <br />• <br />F-1 OWNERtOPERATOR F-1 REGIONAL BOARD <br />COMPANY OR AGEACY NAME <br />ADDRESSREPRESENTING <br />... <br />STATE.. k <br />ET _ <br />PERSON <br />UNKNOWN <br />• <br />ADDRESS <br />r <br />." <br />1491 <br />:, _CITY <br />STATE .. <br />FACILITY NAME (IF APPLICABLE) <br />'OPERATOR i II <br />STREET <br />T PERSON <br />REGIONALCROSS <br />BOARD <br />• <br />r <br />NAME QUANTITY LOST (GAL�L�S) <br />UNKNOWN <br />L�eNKNOWN <br />DATE DISCOVERED <br />♦.EWA'♦ <br />DATE DISCHARGE BEGAN <br />♦ <br />■ • • • +: . <br />« « <br />NO IFYES,DATE+ <br />SOURCEOF DISCHARGE <br />--j <br />TANK LEAK [:;�UNKNOWN <br />SPILL <br />F-� OVERFILL ED RUPTUREIFAILURE F <br />F-� PIPING LEAK 0 OTHER <br />E::] CORROSION NKNOWN OTHER• <br />CHECK •ONLY <br />UNDETERMINED SOIL ONLY GROUNDWATER 0 DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />e O ACTION TAKEN F --j PRELIMINARY SITE ASSESSMENT WORKPLAN • POLLUTION CHARACTERIZATION <br />F --j LEAK BEING CONFIRMED F I PRELIMINARY SITE ASSESSMENT UNDERWAY � POST CLEANUP MONITORING PROGRESS <br />-1 CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) E2/cLEANUP UNDERWAY <br />REM EDIATION PLAN F <br />CHECK APPROPRIATE ACTION(S) EXCAVATE& DISPOSE (ED) REMOVE FREE PRODUCT (FP) ENHANCED 1310 DEGRADATION (IT) <br />tSEE BACK ..MAILS) <br />El CAP SITE (CD) D EXCAVATE & TREAT (ET) F-� PUMP& TREAT GROUNDWATER (GT)F--] REPLACE SUPPLY (RS) <br />F-] CONTAINMENT BARRIER (CB) El NO ACTION REQUIRED (NA) TREATMENT AT HOOKUP (HU) VENT SOIL (VS) <br />VACUUM EXTRACT (VE) OTHER(OT) <br />A <br />