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too . u8 UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES POR:LOCAC AGENCY USE:ONLY . REPORT BEEN FILED YES NO YES NO jHEREW.CERTIFYTHAT1)iAVEDISTRIBUTEDTH(51NEORMATIONACCORDINGTOTHE: ❑ ❑ QISTRIBUTION SHOWN:ON TFIE WSTRUCTION SHEET DN THE BACK PAGE Of:THIS FOAM REPORT/DATE / CASE a ...... '' o v SIGNEII DATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE &7 w REPRESENTING ER�-OWNEWOPERATOR F-1REGIONAL BOARD COMPANY OR AGENCY c ❑ LOCAL AGENCY ❑ OTHER O/V �f p oe ¢ ADDRESS it /f/f*V/� /1li STREET CITY STATE ZIP w NAME CONI!aTPERSON PHONE y �J Zr ❑ UNKNOWN `V D ,\,/YI! v ) � a d ADDRESS STREET CITY STATE ZIP FACILITY NAME(IF APPLICABLE) OPERATOR PHONE o0 y,/ q ADDRESS D-7!i W Y 'INL� , I✓� I✓7`�7'-f J STREET CRY COUNTY ZIP w N CROSS STREET T �� g o w-� O LOCAL AGENCY - AGENCY NAME CONTACT PERSON PHONE zN Lu w w REGK)N�ALOBOAR HONE a 'l l 1 � �n�Q G�Ifi ► ®� F✓tf y (T) u NAME QUANTITY LOST(GALLONS) U 4 0 1 �> ffQ v �¢J 6m-a DL.I JJ 6 C�7 '1t. Z UNKNOWN m O (2) c y Z bt ACL- I V _L� UNKNOWN Z DATE DISCOVERED �! HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURF E MONITORING NUISANC CONDITIONS w MI MI i o O o CJ v v ❑ TANK TEST ❑ TANK REMOVALl OTHER j ) < DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) m a UNKNOWN ❑REMOVE CONTENTS E:]CLOSE TANK&REMOVE �REPAIR PIPING w M M D Y Y p HAS DISCHARSAPPED? REPAIR TANK ❑CLOSE TANK&FILL IN PLACE CHANGE PROCEDURE o ❑ YES YES,DATE ❑REPLACE TANK .OTHER M MI D D V Y SOURCE OF DISCHARGE CAUSE(S) ¢ ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL c o ❑ PIPING LEAK 6j�, OTHER �50 ❑ CORROSION ❑ UNKNOWN ..OTHER U w CHECK ONE ONLY O �j ❑ UNDETERMINED ❑ SOIL ONLY [j4 GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) O CHECK ONE ONLY f ww F-1NO ACTION TAKEN 71PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION Cc y LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS MM� O F-1REMEDIATIONPLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY "'Q CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) J (SEE BACK FCR OEfARS) a ❑ 60 CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) E::] PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) 0 ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) E--�H I \(V ID ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) D `�I -� l;� ��,Y-�� A�►' 1� OCTz 16 2000 td tk s. ENVIRONMENT HEALTH HSC 05(8'90)