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C <br /> qq-p oq <br /> UNDERGROUND AGE TANK UNAUTHORIZED REL (LEAK) CONTAMINATION SITET <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES G USE ONLY <br /> REPORT BEEN FILED? )HE CEf1T1FX ti HANE iSTR19UtEDTHIS(NFt�MtAT .,AC OINGT4TH�: <br /> ❑YES S <br /> 1), BUT SH N.., THE BVSTRUCTIDN SHED ON THE EIACK PAM OF THIS,FORM <br /> REPORT DATE CASE x <br /> ml w( v SKaNEII <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNA RE <br /> 4 pl> a 8 e <br /> m Le <br /> 1 ® / } �. <br /> w REPRESENTING ❑ OWNERlOPERATOR ® REGIONAL BOARD COMPANY OR AGENCY NAME y <br /> 2 LOCAL AGENCY ❑ OTHER r c , ) , , <br /> ¢ <br /> ADDRESS , <br /> ® tt)g,h er <br /> STREET CITY STATE ZIP - <br /> w NAME CONTACT PERSON 7X?) <br /> Paut c .5 z <br /> z ® UNKNOWN P"' <br /> OCL a ADDRESS <br /> co0' <br /> 2 • ® , <br /> STREET CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> O �. <br /> ADDRESS E r4. <br /> ® ' <br /> J s P <br /> 17 5Q 6 <br /> w CITY COUNTY Z(P <br /> CROs STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> Luz- <br /> w <br /> w REG O AL BOA D PHONE <br /> �a <br /> V w (1) E NAME QUANTITY LOST(GALLONS) <br /> Z Jaa <br /> UNKNOWN <br /> m� <br /> — <br /> UNKNOWN <br /> z DATE DISCOVERED DISCOVERED ® INVENTORY ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lu <br /> m ►� D Y Y ®, TANK TEST TANK REMOVAL ® OTHER <br /> co <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> co <br /> ¢ UNKNOWN REMOVE CONTENTS LOSE TANK&REMOVE ❑REPAIR PIPING <br /> w M D Y Y <br /> p HAS DISCHARGE BEEN STOPPED? Q REPAIR TANK ®CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> N YES 'NO IF YES,DATE ml IJ D Y Y []REPLACETANK ®OTHER <br /> Ld w SOUR E OF DISCHARGE CAUSE(S) <br /> 5 ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE I I SPILL <br /> N ❑ PIPING LEAK ® OTHER ❑ CORROSION NKNOWN O OTHER <br /> w w CHECK ONE ONLY c <br /> 0�: a UNDETERMINED SOIL ONLY GROUNDWATER' [:] DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w NO ACTION TAKEN F7PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ 'POLLUTION CHARACTERIZATION <br /> a ❑ LEAK BEING CONFIRMED ❑� PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ` ❑ :REMEDIATION PLAN Q 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 /> : J (�eAGK(Oft DETMB) <br /> wp ❑ CAP SITE(CD) ❑� EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT}❑ REPLACE SUPPLY(RS) <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTON REQUIRED(NA) TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> s ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> w <br /> g e <br /> HSC 05(eno) <br />