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sd <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> t <br /> EMERGENCY HAS STATE OFFICE OF EMERGE Y SERVICES FOq LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 9 a <br /> ❑ YES NO YES ❑ NO :[HEAEHYCERTiFYTHATt HAVEDISTRIBUTEDTHISINFOAMAT10itACCgRDWil TOTHE <br /> .. <br /> DS'i .I.BUTION SHOWN ON THE INSTRUCTION SHEET ON THE.BACK PAGE OF THIS FORM <br /> j sEEl1POR/TDATE _ I II f/ CASE•- - <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> w REPRESE NG ❑ OWNERlOPERATOR ❑ REGIONAL BOARD COMPANY OR'AGENCY NAME <br /> p LOCAL AGENCY ❑ OTHER S p }-�-� <br /> r, ,� 1 <br /> ADDREg , i -� J <br /> STREET CITY STATE <br /> w NAME y�,-� /A_ CONTACTPERSON zir I <br /> C.C3 PHONE <br /> m <br /> z ❑ UNKNOWN <br /> cc ADDRESS OD d �-L' GfJt or — 8�d�r �� 3 5,5 ,etc�'2 6s"I C0 <br /> STATE 71P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> a <br /> c ADDRESS <br /> STREET COUNTY - IP I <br /> y CROSS STREET <br /> z LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w U <br /> w w REGIONALBOARD <br /> y� /PHONE <br /> a a 'R <br /> w {1) NAME QUANTITY LOST(GALLONS) <br /> U O <br /> Z J ❑ UNKNOWN <br /> �y _ <br /> mz <br /> y i ❑ UNKNOWN <br /> Z OOAyTS DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ UBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w (J uI `r MI `� o r I Y ❑ TANK TEST ❑ TANK REMOVAL �Oou R <br /> m DATE DISCHARGE BEGAN / METHOD USED TO STOP DISCHAR TN(CH CK ALL T APPLY) <br /> u D D Y /`N L� /KNOWN ❑AEMOVECONTENTS ❑CLOSE TANK 6 REMOVE ❑REPAIR PIPING <br /> O HAS DISC GE BEEN STOPPED 7 ❑REPAIR TANK ❑CL E TANK&FILL'IN PLACE ❑CHANGE PROCEDURE <br /> U /�J <br /> a YES <br /> E] NO IF YES,OATS (/ O ' ❑REPLACE TANK OTHER I' <br /> M� raI D Y Y <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ja ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL RUPTURFJFAILURE ❑ SPILL <br /> y nPoNG LEAK ❑ OTHER CORROSION ❑ UNKNOWN ❑ OTHER <br /> W Lu CHECKONEONLY <br /> CL <br /> ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> I <br /> CHECK ONE ONLY <br /> Z cn ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMfi7ED ❑ POLLUTION CHARACTERIZATION <br /> BLEAK BEING CONFIRMED ❑ 'PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> rn ❑ REMEDIATION PLAN ❑ .CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> 'CHECK APPROPRIATE ACTIONS) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(ITI <br /> fSWa�GKFORWTALM <br /> a <br /> 00 E7CAP SITE(CD) ❑ EXCAVATE d TRGAT(ET) ❑ PUMP A TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> La <br /> Lu ❑ CONTAINMENT BARRIER(CB) ❑ ACTION REQUIRED(NA) ❑ TREATM T AT HOOKUP(HU) E::] VENTSOIL(VS) <br /> 4 ❑ ^ <br /> VACUUM EXTRACT(VE) OTHER(OT) ��'e.S S <br /> .sper-h Tow Alf-77tz Ti iu . Ta rte.*a.p : <br /> ��. <br /> yw <br /> HSC 05(&sq <br /> I :1 <br />