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UNDERGROUND STORAGE . ANK UNAUTHORIZED RELEASE (LEAK), _JNTAMINATION SITE REPORT
<br />EMERGENCY HAS STATE OFFICE
<br />REPORT BEEN
<br />I I YES ,'NO
<br />OF EMERGENCY SERVICES
<br />ED? FIL
<br />YES NO
<br />FOR LOCAL AGENCYUSE ONLY '
<br />. I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE .: . .
<br />DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM...
<br />d''17:746 '''''' .4.''''
<br />. C
<br />? g-f 1 7 REPORT DATE ,
<br />O 9., Id 5.1 V,4 7,
<br />CASE I
<br />SIGNED . ' . • DATE •
<br />>- ca
<br />NAME OF INDIVIDUAL FILING REPORT ,
<br />k._&-, 1--*/ 4-1 C.._- '3 r 1 i ,:f s
<br />PHONE
<br />obv ii4,8/- .-3 .t6s/
<br />SIGNATURE ‘
<br />2
<br />cr 0
<br />REPRESENTING OWNER/OPERATOR T I EGIONAL BOARD COMPANY OR AGENCY NAME
<br />• 5.4. d: Pl-f S — E /--/ b XLOCAL AGENCY OTHER
<br />a. La cr ADDRESS
<br />3 L E. W.E.,b-e.1/4 S+, _-__Sj-oc etto-vu Cfr
<br />0 i STREET --'C, STATE ZIP
<br />W _.., co
<br />r1)
<br />NAME
<br />. - Pirrvie".A UNKNOWN 1 .,,
<br />CONTACT PERSON
<br />1362-1,A-4 dqc-Kg-On
<br />PHONE
<br />el 6 ) 3 7( — 9'?&6'
<br />0 <
<br />LI,
<br />ADDRESS
<br />e 0 , 6-0--)/5 : i/ 0 Sy— cc— La AL S cf.,,e_.tattlik4 C4 q5 C.. q i
<br />' STR CITY STATE ZIP
<br />z 0 i-, <
<br />T,
<br />FACILITY NAME (IF APPLICABLE)
<br />t , i ,, 1.• „14.1 _ ( Li'er_l( i Z ‘.1- ; Pe) hi el-&‘-1
<br />OPERATOR
<br />cS ct-rki.c..
<br />PHONE
<br />cyiv 37/ — if 74,
<br />ADDRESS - i L5X0C-K(7-)-YL. S i . g5 6.5 A. I 1 6 CITY COUNTY ZIP
<br />CROSS STREET IMPLEMENTING I AGENCIES LOCAL AGENCY AGENCY NAME
<br />5, 3-- , C.L, Pt]c - g Hi)
<br />CONTACT PERSON
<br />Z-e't `4-r'c,„,„ ._
<br />t y3,5
<br />PHONE
<br />(cae?) "it. 4?--3 4 f1,-.
<br />REGIONAL BOARD PHONE SUBSTANCES INVOLVED NAME QUANTITY LOST (GALLONS) .. --1.-- •
<br />UNKNOWN
<br />-4_ ..-
<br />
<br />J
<br />UNKNOWN DISCOVERY/ABATEMENT I DATE DISCOVERED
<br />O 61.
<br />ml lul LI bpi q YI 7 y
<br />HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING I 1 NUISANCE CONDITIONS
<br />TANK TEST TANK REMOVAL OTHER
<br />DATE DISQ HARGE BEGAN
<br />V,
<br />UNKNOWN 6 MI Clul i'DI 0 Q1 I
<br />METHOD USED TO STOP
<br />REMOVE CONTENTS
<br />DISCHARGE (CHECK ALL THAT APPLY)
<br />I I CLOSE TANK & REMOVE REPAIR PIPING
<br />CLOSE TANK & FILL IN PLACE I I CHANGE PROCEDURE
<br />OTHER r ,x) a tz. it
<br />HAS DISCHARGE BEEN STOPPED?
<br /> YES 7 NO IF YES. DATE / 0, D 0 f Q
<br />yi7
<br />IT REPAIR TANK
<br />y
<br />REPLACE TANK SOURCE/ 1 CAUSE URCE OF DISCHARGE
<br />I 1 TANK LEAK I 1 UNKNOWN
<br />PIPING LEAK CZOTHER
<br />CAUSE(S)
<br />OVERFILL
<br />CORROSION
<br />RUPTURE/FAILURE
<br />UNKNOWN
<br />SPILL
<br />OTHER
<br />Lu w In 0_
<br />(I
<br />CHECK ONE ONLY
<br />I UNDETERMINED I SOIL ONLY GROUNDWATER 7 DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) I COMMENTS I REMEDIAL 1 CURRENT I ACTION STATUS CHECK ONE ONLY
<br />Li NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED I I POLLUTION CHARACTERIZATION
<br />PRELIMINARY SITE ASSESSMENT UNDERWAY n POST CLEANUP MONITORING IN PROGRESS
<br />CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY
<br />.X.I,...EAK BEING CONFIRMED
<br />REMEDIATION PLAN
<br />CHECK APPROPRIATE ACTION(S) EXCAVATE &
<br />(SEE SACK FOR DMUS)
<br />I I CAP SITE (CD) EXCAVATE &
<br />I CONTAINMENT BARRIER (CB) El NO ACTION
<br />7 VACUUM EXTRACT (VE) OTHER (01)
<br />
<br />DISPOSE (ED) r--; REMOVE FREE PRODUCT (FP) E ENHANCED BID DEGRADATION (IT)
<br />TREAT (ET) 7 PUMP & TREAT GROUNDWATER (GT) Li REPLACE SUPPLY (RS)
<br />
<br />REQUIRED (NA) I I TREATMENT AT HOOKUP (RU) fl VENT SOIL (VS)
<br />...
<br />49' ' . . i
<br />
<br />. . - . - __ I _ . . . _
<br />rit:Z I S .--& 4 ‘4'(;?.(7 YLeet
<br />“.--; LA.._ .„6_2,--71---7 ,
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<br />z Ze, -et._,,2
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