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Alaas - <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)! CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES tqR.LOCAL:AGENCY]:USE"O.'NLY'". <br /> REPORT BEEN FILED? P0.ffY ...... N.:AC:CORDI'd, <br /> NO DYES NO THATI HAVE,DISTRI�IIJTEDTHIS INFMAt1b, ..N.TO! <br /> HOW THE HE <br /> ❑ ES tHEIET.ON I OF HIS--_WK.PAGEOF.. <br /> REPORT DATE CASES <br /> MATE <br /> NAME OF INDWIDUAL FILING REPORT PHONE SIGNATURE <br /> aREPRESENTING LKUWNE'RIOPERATOR ❑ REGiONALBOARD COMPANY OR AGENCY NAME <br /> AGENCY E:l OTHER <br /> 0 <br /> 0 LOCAL <br /> Lu <br /> cc ADDRESS <br /> 3 7 V111"A' STR er" STATE ZIP <br /> NAME CONTACT PERSON PHONE <br /> c z <br /> o <br /> Fn?: K A I UNKNOWN <br /> 01L ADDRESS <br /> Lu I?�7 <br /> cc ko-L sx-, M-Al /?l-j I crry (14-STATE <br /> FACILITY NAME ff APPI-r-ABLE) PERATOR PHONE <br /> z I T <br /> F- ADDRESS <br /> < L/, co ?-'�67P 3 <br /> 09 /12— TREET CITY AM4- <br /> v L/ <br /> CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE ff <br /> 14 <br /> Lu <br /> Lmu LzLjREGrIONAL 8 D PHONE <br /> S; -GuIQ W-cua03 <br /> u NAME QUANTITY LOST(GALL0 S) <br /> LU 0 L <br /> Lu KNOWN <br /> > <br /> 0 <br /> co> (2) <br /> Z <br /> UNKNOWN <br /> C.0 <br /> z <br /> DATE DISCOVERED HOW DISCOVERED Q INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONmS <br /> ❑ TANK ST [:] TANK REMOVAL ❑ OTHER <br /> 0 c DATE DISCHARGE BEGAN METHOD USED TO STOP 0 C RGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑REMOVE( CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> 6 HAS DISCHARGE BEEN STOPPED 7 ❑ <br /> ml ml DI Yl yl �F <br /> Lu REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> L) <br /> D YES O-C) NO IF YES,DATE O.Izj REPLACE TANK E]OTHER 7yi 7 l <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> L wOVERFILL <br /> 1SPILL <br /> L) E] RUPTURE/FAILURE 0 F-� TANK LEAK lg� <br /> D <br /> 0 <br /> F-1 PIPING LEAK E:j OTHER r--j CORROSION UNKNOWN ❑ OTHER. <br /> Lu La CHECK ONE ONLY <br /> V)(L <br /> 6� ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY SEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z ❑ NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> W< LEAK ❑ POST CLEANUP MONITORING IN PROGRESS <br /> LEBEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY <br /> REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) 0REMOVE FREE PRODUCT(FP} ❑ ENHANCED BID DEGRADATION(IT) <br /> j�&4K fCR DttA ffl <br /> ZREPLACE SUPPLY(RS) <br /> Ei 0 ❑ CAP srm(CD) ❑ EXCAVATE&TREAT(ET) E] PUMP&TREAT GROUNDWATER(GT)❑ <br /> Q ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) [�j TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> w< <br /> VACUUM EXTRACT(VE) ❑ <br /> OT14ER(OT) <br /> *lAAAA1alAh-- <br /> lz <br /> 0 <br /> k% HSC 05(s" <br />