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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 COl AMINATION SITE REPORT <br /> EMERGEN HAS STATE OFFICE OF EMERGE CY sEav�ct s FOR LOCALAGENCY ONLY <br /> 11 REPORT BEEN FILED 7 1 HEREBY CERTIFY THAT.( HAVE DISTRIBUTED THIS INFORMATION ACCORDING 30 THE <br /> ❑ YES NO ❑ YES NO <br /> DISTRIBUTION SH OWN ON THE INSTRUCTION SNEEi ON THE BACK PAGE OF.THIS FORM.:,,;;..; <br /> REPORT DATE CASE s ,� <br /> M c?M, �� y 1 <br /> 'SIGNED : <br /> NA ��OFNDIV;OVAL FILING FfFP PHONE SIG <br /> WVA_�71 7%0�3�f <br /> REPRESENTING REGIONAL BOARD COMPANY OR AGENCY NA <br /> F ❑ OWNER/OPERATOR ❑ <br /> pLOCALAGENCY ❑ OTHER <br /> ¢ ADDRESS <br /> 1,30 C/ <br /> sTAIE �S z1R <br /> w NA(MEE"J CQT PE SONve, <br /> y� PAHO( <br /> NE <br /> co <br /> ii ! p Cl�L ❑ UNKNOWN �/'-1-n A— (Y'[ <br /> a a ADDRESS 7 <br /> Q � �.r ;l� , IC��U G STATE <br /> STRE <br /> FACILITY NAME(IF APPLICABLE) 7 OP `ATO PHONE <br /> Z <br /> 0 <br /> F ADDRESS r <br /> w �� - ,,,J ( V "'`STRE t ✓ / �/ �Y L-i !TY �V aLr LOU /`r`� i x�Vi <br /> ~ CROSS STREET <br /> Ll LOCAL AGENCY AGENCY NAME CSN T PERSO PHONE <br /> wYD <br /> w w REG)ONALBOARD�/ f PHONE <br /> a a <br /> ()) NAME OUANTITY LOST(GALLONS) <br /> i we4�1 ❑ UNKNOWN <br /> Q J •/ <br /> 6e'­ <br /> cm Z (z) <br /> r=n_ / JI r`' ❑ UNKNOWN <br /> z DATE DISCOVFXD / HOW DISCOVERED VENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lu <br /> w MIC/ MIp� p Y` Y 0 TANK IES TANK <br /> REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> w M M D Y Y <br /> HAS DISCHARGE BEEN STOPPED 7 0 REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> L4 - L <br /> YES ❑ NO IF YES,DATE M �MI D D v y ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ui j a ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURElFAILURE ❑ SPILL <br /> v ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w w CHECK NE ONLY <br /> U UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER •(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z E-1NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w <br /> r LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTIONS) ❑ EXCAVATE a DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> {SEE s FOR OET. 51 <br /> a Z ❑ CAP SITE(C01 ❑ EXCAVATE&TREAT(ET) E::] PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> 2 . <br /> 0 O <br /> wr <br /> L) ED CONTAINMENT BARRIER(CB) ❑ NO ACTION REO RE (NA) ❑ EATMENT AT HOOKU ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) G <br /> En <br /> 0 <br /> 0 <br /> U <br /> HSC 451&9q <br />