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REPORTTE <br />�, , <br />EMERGENCY HAS .. <br />OF EMERGENCY SERVICES <br />YES YES <br />►� Or - <br />A <br />NAME OF INDIVIDUAL FLING REPORT <br />AGENCY NAM <br />T PERSON <br />PHONE <br />w� <br />- <br />G e <br />REPRESENTING <br />OWNEROOPERATOR F7 <br />GIONAI BOARD <br />� <br />LOCALAGENCY OTHER <br />UM <br />RESS <br />ADDAlm <br />�4N,+ ® <br />PHONE <br />() 0530 <br />PHONE <br />C'� isa`l <br />9 <br />LOCAL AGENCY <br />AGENCY NAM <br />T PERSON <br />PHONE <br />w� <br />- <br />G e <br />W W <br />L i <br />GIDNAL <br />� <br />PHONE <br />�4N,+ ® <br />(11 ®NAME <br />55ANTITY POST <br />Lu <br />UNKNOWN <br />�>eon <br />fA <br />j <br />ve <br />❑ UNIGIOWN <br />r- <br />w <br />DATE DISCOVERED <br />/ <br />HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE ONRO IPK3 NUISANCE CONDITIONS <br />�� <br />12 <br />-(y, vw l/ o <br />Y <br />❑ TANK TEST ® YANK REMOVAL OTHERM r <br /><m <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />w <br />w <br />UC•hCN01AiN <br />❑ REMOVE CONTENTS F-1CLOSETANK A REMOVE ❑ REPAIR PIPING <br />HAS DISCHARGE BEEN STOPPED? <br />❑ REPAIR TANK ❑ CLOSE T i FI.L W PLACE CHANGE PROCEDURE <br />y <br />� <br />YES ❑ NO IF YES. DATE <br />w � <br />REPLACE TANK ° <br />❑ OTHER <br />SOURCE OF DISCHARGE <br />y Y <br />CAUSES) <br />❑ TANK LEAK <br />UNKNOWN❑ <br />OVERFILL ® RUPTURE/FAILURE ® SPILL <br />L) <br />❑ PIPING LEAK <br />❑ OTHER <br />❑ CORROSION ❑ OTHER <br />a <br />CHECK ONE ONLY <br />v <br />UNDETERMINED ❑ <br />SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECC ONE ONLY <br />H y <br />Q < <br />❑ NO ACTION TAKEN <br />® PRELWINARY SRE ASSESSMENT WORKPLAN SUBMfTTED ❑ POLLUTION CHARACTERIZATION <br />cc <br />H <br />F-1LEAK BEING CONFIRMED <br />PRELIMINARY SITE ASSESSMENT UNDERWAY ® POST CLEANUP MONITORING <br />❑ REMEDIATION PLAN <br />IN PROGRESS <br />❑ CASE CLOSED (CLEANUP K:OMPLETED <br />OR UNNECESSARY)® CLEANUP UNDERWAY <br />J <br />CHECK APPROPRIATE ACTION(S) <br />(f9!MCe6 MR OC4A°q <br />13EXCAVATE 6 DISPOSE (ED) ❑ REMOVE FREE PROOUCT (FP) f7 ENHANCED BID DEGRADATION (IT) <br />WQ <br />❑ CAP SITE (CO) <br />❑ EXCAVATE A TREAT (0) - ❑ PUMP 3 TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />cc � v <br />< <br />CONTAINMENT BARRIER (CB) <br />❑ ❑ NO ACTION REOUfRED (WIA)EDTREATMENT AT ROOKUP (RAR) ❑ VENT SOIL (VS) <br />❑ VACUUM EXTRACT (VE) <br />OTHER (OT) <br />mw as <br />