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��A 6W6' <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />FOR LOCAL AGENCY USE ONLY <br />❑ YES ly"NNO REPORTBEEN FILED? [::]YES ❑ NO <br />�l <br />1 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 />REPORTDATE <br />CASE <br />AA 6-.1 I I <br />LYGwe <br />'SIGNED AV ✓ DATEO <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE <br />m <br />arv/ O- <br />(Zo➢1 u68-3yyo <br />L <br />w <br />REPRESENTING O OWNERXWERATOR ❑ REGIONALBOARO <br />COMPANYOORAGnNCYNAME <br />, (,(L %� <br />4 <br />i <br />�OCAL AGENCY ❑ OTHER <br />SiNS r S VI%on .1jet . / ✓ /✓• <br />It <br />ADD3vy E N/eler , 1/4L'- . S�v C-K7,6,n Gg 95 2-0/ <br />STREET CRY STATE 21P <br />w <br />NAME <br />CONTACTPERSON <br />PHONE <br />J <br />im <br />,T <br />QL(�Y Al *4 Azee UNKNOWN <br />tol d m <br />/� <br />(2o?)E/6t/- <br />H y <br />Q <br />ADDRESS <br />& 3-7 lee /e Sb 9/ <br />-e STREET CRY STATE Zip <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR PHONE <br />o <br />urk +-SR✓e i'j'J6cr�Gf" <br />lC�ia/I[i q/�ino (20g1Ybr! a�6 <br />s <br />ADDRESS <br />& u/ C C�urfcr <br />gREET CITY <br />y <br />CROSS STREET <br />S 4-a n -t /a rti <br />O <br />LOCAL AGENCY AGENCY NAME <br />CONTACTPERSON <br />PHONE <br />z <br />h.� rA Co. LC d17� <br />rJ/ 07_ <br />(2F�Y146 3yYa <br />. <br />ww0 <br />REGIONALBOAR <br />PHONE <br />a a <br />s <br />( I <br />y <br />(T) NAME QUANTITY LOST (GALLONS) <br />0 <br />a /iGti n'1 Aj dA [L�UNKNOWN <br />IC <br />-O r 10,14 <br />In <br />m <br />y <br />❑ UNKNOWN <br />DATE DISCOVERED <br />NOW DISCOVERED ❑ INVENTORY CONTROL SUBSUR,�ACE ❑1 NUISANCE CONDITIONS <br />x,11 <br />D SM C I o r r <br />❑ TANKTEST ❑ TANK REMOVAL [:3 OTHER <br />m <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />MI ol r UNKNOWN <br />❑ REMOVE CONTENTS ❑ CLOSE TANK & REMOVE ❑ REPAIR PIPING <br />w <br />❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED? <br />o <br />❑ YES ❑ NO IFYES.DATE <br />F-1 REPLACE TANK QOTHER <br />ml uI DI dY v <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />❑ TANK LEAK UNKNOWN <br />❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br />y0 <br />❑ PIPING LEAK ❑ OTHER <br />❑ CORROSION ❑ UNKNOWN ❑ OTHER <br />ywn <br />CHECK ONE ONLY <br />O <br />UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />wZ <br />❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />m <br />❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />O <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE& DISPOSE (ED) REMOVE FREE PRODUCT (FP) ENHANCED BIODEGRADATION (M <br />tiff wxwSOET.AA <br />wg <br />❑ CAP SITE (w) ❑ EXCAVATE& TREAT (ET) ❑ PUMP& TREAT GROUNDWATER (GT) REPLACE SUPPLY IRS) <br />w a <br />❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />❑ VACUUM EXTRACT (VE) ❑ OTHER (OT) <br />yS70;/m7ni <br />46 S70 6cof m Ve&dr,'�j (,'P% y00pr1m! <br />2 <br />Odra Soi/ drsco%nwfz;k P44-6 .erJ iter- 3s -4--k <br />-47-04AX. <br />O <br />U <br />