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HSC 05(4w) <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) ! CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGYeY SERVICES <br />REPORT BEEN FILED ? <br />FOR LOCALAGENCY USE ONEY <br />1>}iERE9Y <br />❑ <br />YES EVNO YES ❑ NO <br />CERTIFk THAT I AM It (7E&IGNATEO GOVEREMPLOYEE. ANRTFSAT<.I }(AVE:.. <br />FiEPORTEDJHIS fNFORMATION,:TO LOCAL OFF[CU(E5 F(lRSUANT TQ SECT[0'f 25S.8Q7 OF> <br />REPORTOATE CASE# <br />TH 11 SpF(y - <br />3M .1 2yjr <br />f ATE f <br />NAME OF INDIVIDUAL FILING REPORT PHONE II SIGNATURE <br />C <br />m <br />es lv <br />C� <br />in <br />REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONALBOARD <br />COMPANY OR AGENCY NAME <br />p <br />R <br />LOCAL AGENCY OTHER <br />Aj % il�i� <br />v �I/c <br />A06FIESS <br />i <br />I <br />r3q3t7 <br />6;, <br />STREET <br />CrT STATE O ZIP <br />NAME <br />CONTACTPERSQN <br />€ <br />PHONE <br />m� <br />� <br />�f�U ❑ UNKNOWN <br />' <br />CS <br />L <br />ADDRESS <br />/� <br />7 <br />Fd <br />. : /� STREET <br />Ciry i STATE 2SP <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR ? <br />ONE <br />Q <br />J� <br />P <br />!PI <br />ADDRESS <br />I? <br />�0�I <br />�v <br />STREET M-� <br />CITY i %U COUNTY ,�j P <br />CROSS STREET <br />TYPE OF AREA ❑ COMMERCIAL INDUSTRIAL❑ RURAL <br />TYPE OF BUSINESS. � RETAIL FUEL STATION! <br />�NG�ir!s-fir� <br />g <br />❑ RESIDENTIAL ❑ OTHER I} <br />❑FARMu/OTHER <br />p <br />LOCALAGENCY AGENCY NAME <br />CONTACTPERSON II, <br />ZPHONE <br />W <br />_ <br />m1G", reps <br />u <br />(port J 4?-3WO <br />8 <br />w <br />(L <br />REGIONAL BDA RD <br />I? <br />PHONE <br />(S) t NAME <br />QUANTITY LOST (GALL?X) <br />r to v 6�j1 <br />EOUNKNOWN <br />(Z) <br />_ <br />y <br />❑ UNKNOWN <br />z <br />DATE DISCOVERED <br />HOW DISCOVERED VENTORY CONTROL F --]SUBSURFACE MONITORING E]NUISANCE CONDITIONS <br />ui <br />.1 o r r <br />❑ TANK TESTANK REMOVAL ❑ OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP, DISCHARGE (CHECK ALL THAT APPLY) <br />u <br />ED <br />M M a o v v UNKNOWN <br />REMOVE CONTENTS E] REPLACE TANK CLOSE TANK <br />Lu <br />❑ REPAIR TANK ; ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br />i <br />HAS DISCHARGE BEEN STOPPED? <br />YES ❑ NO 1F YES. DATEDMI � � 3o ?,10, <br />❑ OTHER 3i <br />y <br />SOURCE OF DISCHARGE <br />❑ TANKLEAK UNKNOWN <br />TANKS ONLYiCAPACITY <br />�7Ci� GAL. <br />MATERIAL Il <br />❑ F ERGLASS I <br />CAUSE(S) <br />❑ OVERFILL PTUREIFAILURE <br />❑ PIPINGLEAK <br />AGE k YRS <br />VTEEL 'I} <br />❑ CORROSION VUNKNOWN <br />❑ OTHER <br />❑ UNKNOWN <br />❑ OTHER i <br />SPILL ❑ OTHER <br />w� <br />u <br />CHECKONEONLY I <br />II <br />❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER <br />❑ DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ON: ONLY <br />'SIGNED <br />It ¢ <br />❑ SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ OFF (CLEANUP COMPLETED Oft UNNECESSARY) <br />V y <br />❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS <br />❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />{ <br />z <br />❑ CAP SITE (CD) ❑ EXCAVATE & DISPOSE (ED) <br />❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />o O <br />CONTAINMENT BARRIER (CB) ❑ EXCAVATE & TREAT (ET) <br />i,.. <br />❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />TREATMENT AT HOOKUP (HU) NO ACTION REQUIRED (NA) <br />OTHER (OT).! <br />/Qeyrovc SQ, tau r -r'Vea Soll <br />5� moi// �' • rairY -?d f Ate <br />z <br />asp s rrfAt.� <br />*'�ir�e <br />C Caa':�1/n�r>/div �j�P_ [�/ �/ r�/circ? <br />4!7p PS <br />/ ✓ <br />ii <br />HSC 05(4w) <br />