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-u8o <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY ry HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCHERESYAGAGENOY USE ONLY <br /> ❑ YES L? ND REPORTBEEN FLED? ❑YES NO REPORTED ET�hTIFI THAT I AM 1 0 SIGNATED LOCAL OFFICIALS NMENT EMPLOYEE AND THAT I PURSUANT TO SECTION 251803OVE <br /> F <br /> REPORT DATE CASES THE HEALTH AND <br /> 0.1 & 2' a Yl v DATE <br /> SMIeINDIVIDUAL eFILING f-yo � PHONE B-�D SIGN TUR <br /> q <br /> REPRESENTING ❑11VV''IIFF1I011.•W/ERAOF ATOR ❑ REGIONALBOAARRD/()I COMPANY OR AGENCY NAME'//T <br /> ¢O LOCAL AGENCY ❑ OTHER <br /> a <br /> ADDRESS (�/ `/ .. 1 //�//J� <br /> 2 / TREET N G Y SKATE � ETA <br /> 2 NAMEn CONTACT PERSON PHONE $yj <br /> ¢ K f'�' &,o e ❑ UNKNOWN L�C�-- (2b/9 334-Zf) <br /> S a ADDRESS <br /> {G^y- <br /> 2 STREET � I CRY SrRTE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> Qj' o- pI tL09>334 ZI IL <br /> i ADDRESS <br /> 0 srnEU Cm ap <br /> y CRO STREET TYPE OF AREA COMMERCIAL❑NDUSTRIAL❑RURAL TYPE OF BUSINESS 0 RRJEJTAIILFUELSTATK]N [� <br /> RESIDENTIAL ❑OTHER E:] FARM 'OTHER ) G(,N[� [T <br /> LOCALAGENCY qq���� ,R� �� AGENCYNAME NTACTPERS//ON P'/HH/OO�NIE <br /> MI . msa�j <br /> w fi <br /> w REGIONAL BOARD P NE <br /> g G. <br /> NAME OUANTRY LOST(GALLOy8) O <br /> Hsu 6*,cu 0 UNKNOWN <br /> ET-6NKNOWN <br /> DATE DISCOVERED (� HOWDISCOVERED ❑ T <br /> INVENTORY CONTROL ❑ SUBSURFACEMONIORNG ❑ NUISANCE CONDITIONS <br /> OM u .19 .1 ❑ TANK TEST jie'TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M u D o Y v �UIKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK DRr CLOSE TANK <br /> 4 HAS DISCHARGE BEEN STOPPED 4 ❑ REPAIRTANK ❑ REPAIR PIPING E::] CHANGE PROCEDURE <br /> p ❑ YES � NO IF YES,DATE ®M M D V//j D / YU v ❑ OTHER <br /> yk SOURCE OF DISCHARGE TANKS <br /> /O-�NLYYA,.:.A�PAGC.IITY MATERIAL CAUSE(S) <br /> ❑ TANKLEAK DISCHARGE <br /> LV.=D GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUHEFAILURE <br /> ❑ PIPNGLEAK AGE YRS STEEL ❑ CORROSION To�JNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> CHECK ONE ONLY <br /> UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ��SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS a SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> �N ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE a DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE 6 TREAT(ET) ❑y PUMP&TRFATGROUNDWATER(GT) [:] RREE.P,L.AACG,ElSUPPLY(RS) <br /> F-1TREATMENTAT HOOKUP W) ❑ NO ACTION REQUIRED INA) /may OTHER(OT)SLTr-- 10 �`tJ11MJICsI,"IT �� <br /> t2SLi� IS P tF.T7 ) � L>flc.Az_ UC�T ()gef6[Lv � PR0&'RkYI F&' <br /> Z. CoF -nVzu.G—h> I,t,3 GOIL Al-AIaa2 <br /> C-pAta.uA Ulfi-�2- C�'►�'t14i'VL�,N f1'C"�-o�r.1 . <br /> HBCR(4AU) <br />