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UNDERGROUND STORAGE TANK UNAUTHORIZED REL EA SE (L EAK)'I-CONTAMINATION SITE REPORT <br /> EMERGENCY{ HAS STATE OFFICE OF EMERGENCY SERVIC <br /> REPORT BEEN FILED? ' <br /> MR LOCA :AGENCY:USE ONLY <br /> YES NQ YES ND IHEREBYC FYTHATI HAVEllISTR19UTED: IS INFORMATION;ACCWDINGTOTk <br /> - SISTA UT SHOW ONTHEINSTRUCTIONtitEETONTHEBACKPAGEflFTHISFORM:- <br /> REPORT DATE <br /> CASE <br /> /� <br /> M M / Y :SIGNED DATE ..: <br /> NAME <br /> OV INDIVIDUAL FILING REPORT !PHONE SIGNATURE <br /> w REPAESE G OWNERrOPERATOR Q REGIDNAL BOARD COMPANY R AGENCY NAME <br /> LOCAL AGENCY Q OTHER Sf301 <br /> Lij <br /> ADDRESS /�]p <br /> 6+ .RE - CRY • 5f ATE - ZIP <br /> w NAME CONTACWEAWN PHONE <br /> Jc �.,rljT� q ' <br /> z � �]e } UNKNOWN <br /> o ac <br /> 0 a DDRESS <br /> w <br /> o• <br /> STREET rr" STATE <br /> FACILI NAME(IF APPLICABLP. OPERATOR /PHONE ` <br /> zo S A ! <br /> a ADDRESS <br /> O13 :. - STREET s� CfTY GOUHTT'"j Z <br /> y CROSS, TREET <br /> O LOCAL AGENCY AGENCY NAME CONTACT P 5RSON PHONE <br /> Lu <br /> w REGIONAL BOARD PHONE <br /> g 1 ' <br /> rn (t} NAME QUANTITY LOST(GALLONS) <br /> i w G/9 r 1. 0 I �! KN <br /> NOWN <br /> �'4� <br /> m z (z) <br /> N UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED' I NTORY CON ROL SUBSURFACE MONITORING' E] NUISANCE CONDITIONS <br /> O TANK TEST TANK REMOVAL OTHER <br /> M. M .. . A O yl,. <br /> Y <br /> a DATE DSSGHARGE BEGAN METHOD USED TO STOP DISCHARG J CHECK ALL THAT APPLY) <br /> 321 5� UNKNOWN Q FIEMC VE CONTENTS 2100GLOSE TANK&REMOVE E:]REPAIR PIPING <br /> Lu 'Mf- -M D D 'Y, Y ,j.r <br /> 6HASfl1§ �ttNbTOP?Eb?, C]REPARTANK"; F]CLOSETANK&FILL IN PLACE CHANGE PROCEDURE <br /> ( '�]`� YES' NO IFYES.DATE µ / MI D D,b "I <br /> / r REP CE TANK,. OTHER <br /> C] <br /> SOURC DISCHARGE CAUSE(S) <br /> w <br /> jTANK LEAK .UNKN0INN OVERFILL RUPTURElFAILURE SPILL <br /> vEl PIPING LEAK OTHER CORROSION UNKNOWN , OTHER <br /> W wa CHECK :ONLY AMC AIM <br /> U UNDETERMINED SOILONLY GROUNDWATER Q DRINK) G WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY; <br /> z'n TION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN 3usmiTTED POLLUTION CHARACTERIZATION <br /> w <br /> ccr LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY :POST CLEANUP MONITORING IN PROGRESS <br /> L)rn 0 REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) D ENHANCED BIO DEGRADATION IIT) <br /> J 18EE BACK FOR CE7us) . <br /> a o F-1CAPSITE(CD) 0 EXCAVATE&TREAT(ET) 0 PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> w a CONTAINMENT BARRIER(GBy NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) F VENT SOIL(v5) <br /> VACUUM EXTRACT(VE) ER(OT) <br /> z <br /> Q <br /> U <br /> HSG 05IWO) <br />