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UNDERGROUND STORAGE TAK UNAUTHORIZED RELEASE(LEAK)/dUNTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVISET FOR LOCAL,';AGENCY USE ONLY <br /> REPORT BEEN FILED 9 <br /> S YES NO YES NO 1 HEREBY CEfMFYTHAT I I HAVE OISTMUTED THIS INFORMATION ACCORDING TO THE <br /> DISM[BUTION SHOWN ON THE INSTRUCTION SHEET ON THE 8XK PAGE OF THIS FORK <br /> REPORT DATE CASE <br /> 1 1 TE <br /> NAGE �INIaIVI�t� FAL, -REPORT PHONE SI <br /> } IIE I ESEN Tttd€B NE R T?R C$ECa CNAt (tt PAW OR AGENCY NAME <br /> ( <br /> LOCAL AN OTHER <br /> z ' <br /> ADDRESS <br /> T r STATE � <br /> NAME T T PEEN <br /> RS <br /> UNKNOWN <br /> o< ADDRESS <br /> FACILITY NAME(IF PL L ) OPERATOR PHONE <br /> STREET L <br /> ro i C OSS STREET <br /> L ALA NCY <br /> AGENCY NAME CONTACT PI R CJPd PHONE <br /> Lu u'l RINALAR <br /> 4 3 <br /> NAME OUANTITY LOST t LLONS <br /> Lu UNKNOWN <br /> () <br /> UNKNOWN <br /> ISA T E DI VERECB HO DISCOVERED INVENTORY CONTROL � SUBSURFACE MONITORING � NUIS E N23tT31CIht a <br /> i E TANK ItST T OTHERK REMOVAL � <br /> 06i; hiDATE D$ H R aE BEGAN THOO <br /> USED To STIP DISCHARGE <br /> (CHECK ALL THAT APPLY) <br /> UNKNOWN <br /> RER E CINTENTS CLOSE <br /> TANK REMC}VE REPAIR PiPI <br /> HAS 13t I i E BEEN ST PEO? REPAIR TANK CLOSE TANK FILL W PLACc [:]CHANGE PROCEDURE <br /> YES IYE—K 0 .SATE �lhiiI 3 RE E TANK ETHER <br /> �IURCE DISCHARGE CAUSE(S) <br /> TANK LEAK UNKNOWNOVERFILL R AILLlRE Pitt <br /> 7 <br /> 8 f r-3 PIPING> 1 OTHER R SI N UNKNOWN � OT}HER <br /> Asx aax CHECK ONE ONLY <br /> i t3tIpET ERMS S(TIL csNl Y c LIN ATER (RSNK TATE .(CHEC INLY sF CATER LLQ I�AVVE A TLSAU Y BEEN AFFECTEO) <br /> HS <br /> ECK ONE ONLY <br /> } ACTION TAKEN CD PRELIMINARY SITE ASSESSMENT R NSUBMITTE�I � POLLUTION 3IARACIERi 4ttC3�1 <br /> �1PCISTCLE UP MONMORING IN PROGRESS <br /> rM <br /> LEM BEING CONAIRMEO PRELIMINARY SITE ASSESSMENT UNDERWAY <br /> # CASE CLa SSO(CLEANUP CoMpLSTED OR UN CES A4) CLEANUP UNDERWAY <br /> { R MFOIATION PLAN <br /> CHECK ApPILEIF'RRA?E ACTION(S) ECAVATF A DIS E(ED) � REMOVE FREE PR U T(EP) � ENI CEIJ BICC I: R E CE�idd tI I} <br /> SCAP ITE—(CO) EXCAVATE, TREAt"(S I� PUMPTREAT C�Rt tJNIJtiVA 3 ER{G I)� REPLACE SUPPLY Y INS)fi TRFA ENT AT HOOKUP(HUI VENT IL(VS) <br /> # NTAtNMNT BARRIER dC83 L] NO ACTION REuE�1(NA) .moi <br /> VACUUM EXTRACT(VE) OTHER(OT) <br /> I ase o5 Wml <br />