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(fl -L43 <br />UNDERGROUND STORAGE 1 ANK UNAUTHORIZED RELEASE (LEAK) i GONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />REPORT BEEN FILED? ..ts1.,- <br />I I YES NO YES NO <br />.• FOR LOCAL AGENCY USE ONLY .• . ,' .. . :. . . . . . <br />. 1 HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE •-, - <br />DI • :U ION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM.. - <br />I ---7. c.... • : • •• : <br />i eZ... • '.).Air 2 0 _ .-_-.• <br /> <br />0 <br />.,- <br />S <br />IGN.A. <br />REPORT DATE <br />LI Q.41 d 'I?' qv' 7Y <br />CASE a <br />dr DATE. . <br />›- co <br />NAME OF INDIVIDUAL FILING REPORT <br />l <br />Lilt t A c4"--- r 1 3 25 <br />PHONE <br />(O?) 1746F-3W, <br />SIGNATURE <br />217, . <br />2 )-• rr 2 <br />REPRESENTING OWNER/OPERATOR REGIONAL BOARD <br />X LOCAL AGENCY OTHER <br />cf COMPANY OR AGENCY NAME <br />hi jo&far,_Ze , S — L , <br />,.7 <br />1) - ; P 0 /1 & <br />LA cc ADDRESS <br />_3 0 if L{),/, St; S -/-e , 11"-/-o- Cfi <br />STREET CITY STATE ZIP <br />w _J <br />z, <br />NAME <br />R i 0-61( &&. Pe tr o_lea UNKNOWN <br /> <br />CONTACT PERSON . <br /> <br />DA t) 6 j7q-C f(-5-'eh'z. <br />PHONE <br />( 0 ) 37/- 9'.F6es- a_o Lc .., <br />IL <br />ADDRESS S W , _2.-crq,nwint C A- -,5 6 9-7 <br />STREET CT' STATE ZIP SITE LOCATION I I . FACILITY NAME (IF APPLICABLE) <br />I 1)-6k , el-- Pr-,0iezvypt.„ <br />OPERATOR <br />R ,- yet, e_i_.,ty i-Tk 71710 teu.frrt , <br />PHONE <br />( ) <br />ADDRESS <br /> <br />—5-/VGi6Lt.51-vt_.- <br /> ' 11, l CITI ti ZIP '' 3 STREET CO,5-6( We <br />CROSS STREET <br />PcbiAl d a..&_. , IMPLEMENTING AGENCIES LOCAL AGENCY AGENCY NAME <br />,Sa/ri -..• a tit,v,, e6, PYs-EHD h- <br />CONTACT PERSON c PHONE . . . <br />REGIONAL BOARD <br />Ruul 6? C - E)) <br />J,..../ PHONE <br />( ) I SUBSTANCES DISCOVERY/ABATEMENT INVOLVED NAME QUANTITY LOST (GALLONS) <br />,UNKNOWN <br />1 <br />UNKNOWN <br />DATE DISCOVERED <br />..._ c I .1 0 mi DI Di ? Y1'7 Y <br />HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE <br />ss <br />CONDITIONS. <br />TEST TANK ST TANK REMOVAL .S. OTHER 14 _e gs-- yriz.41:6 (p r e I <br />DATE DISCHARGE BEGAN <br />M1 ml 01 01 ,I yl X UNKNOWN <br />METHOD USED TO STOP <br />REMOVE CONTENTS <br />DISCHARGE (CHECK ALL THAT APPLY) <br />1 1 CLOSE TANK & REMOVE 1 I REPAIR PIPING <br />I 1 CLOSE TANK & FILL IN PLACE L1 CHANGE PROCEDURE <br />1 OTHER <br />HAS DISCHARGE BEEN STOPPED? <br />DATE ‘41 1.41 DI 01 y1 y <br />REPAIR TANK <br />REPLACE TANK 1 1 YES NO IF YES. SOURCE/ I CAUSE SOURCE OF DISCHARGE <br />1 1 TANK LEAK <br />fl PIPING LEAK OTHER <br />XUNKNOWN <br />CAUSE(S) <br />OVERFILL 1 RUPTURE/FAILURE <br />CORROSION \><:C UNKNOWN I <br />SPILL <br />1 OTHER <br />Lm w <br />ti <br />CHECK ONE ONLY <br />UNDETERMINED fl SOIL ONLY GROUNDWATER DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) REMEDIAL I CURRENT I ACTION STATUS HECK E ONLY <br />NO ACTION TAKEN <br />1 1 LEAK BEING CONFIRMED <br />1 1 REMEDIATION PLAN <br />PRELIMINARY SITE <br />PRELIMINARY SITE <br />ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br />ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br />COMPLETED OR UNNECESSARY) I 1 CLEANUP UNDERWAY CASE CLOSED (CLEANUP <br />CHECK APPROPRIATE ACTION(S) X EXCAVATE & (SEE BACK F.31 OVALS) <br />I I CAP SITE (CD) EXCAVATE & <br />1 I CONTAINMENT BARRIER (CB) E NO ACTION <br />7 VACUUM EXTRACT WE) 7 OTHER (OT) <br />DISPOSE (ED) REMOVE FREE PRODUCT (FP) in ENHANCED BIO DEGRADATION (IT) <br />TREAT (ET) PUMP & TREAT GROUNDWATER (GT) I I REPLACE SUPPLY (RS) <br />REQUIRED (NA) 1 1 TREATMENT AT HOOKUP (HU) 1 I VENT SOIL (VS) 1 COMMENTS I ‘..c.z.,". <br />A ejet---,64 ,ze44,-i--- <br />a-- L4..,/.41 <br />._L_-, <br />, <br />-d441,1.14-- Z '(-- "-(--'- e ,--.‘-1 , A.- (ir .Z Z. ed• <br />w a.1-tAe _. `,/ • /./:_)/