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0 0 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ VES �NO REPORT BEEN FILED 7 E]YES ❑ NO 1 HEREBY CERTIFY THAT I AM A.DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED/THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> THE HE0.LT}1 ANO SAF(Y COD6 <br /> REPORT DATE CASE I ' <br /> OM 1 M 1 y o g Y Y SIGNED DATE <br /> ........... <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> DgvYd C-pls (2.61)4168- S9go <br /> q REPRESENTING O OWNERLOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> LL <br /> p LOCALAGENCY ❑ OTHEfl Low I�e.(IL, DSS-Tr�C1 <br /> ADDRESS n �1� <br /> 1601 E NA4e4ol p-1. 9'w 2,. ,, S'Eoc1cTN� GA 4S2o1 <br /> STREET CffY STATE 21P <br /> NAMET El UCONTACTPERSON PHONE <br /> m� F S F 2Nv�C C•.'t5 NKNOWN ( ) <br /> <y ADDRESS <br /> M�rct-d GA 4SSVo <br /> STREET cm WATE Bp <br /> FACILITY NAME(IF APPLICABLE) 1 OPER(AJTOR PHONE <br /> Q SC.�n VO uiN -lt�-lr�L T.^t. Tia g-�wNaL.� (Zoll) 465 S42fr <br /> ADDRESS <br /> �y 53S Vh1er� J`. STREET C" C(Jm Q P <br /> yCROSS STREET TYPE OF AREA ❑COMMERCIAL ❑INDUSTRIAL ❑RURAL TYPE OF BUSINESS ❑ RETAIL FUELSTATK)N <br /> o.k SFll- ❑RESIDENTIAL ❑OTHER ❑ FARM 0 OTHER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> N ( ) <br /> W S� <br /> w� REGIONAL BOARD PHONE <br /> w (1) NAME QUANTITY LOST(GALLONS) <br /> LL1 2h�thL ® UNKNOWN <br /> (2) <br /> �- AS O`T�e— UNKNOWN <br /> DATE DISCOVERED HOWDISCDVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCECONDITIONS <br /> I M 0.1 1 DI 5- <br /> 0 ff YJ Y ❑ TANKTEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN �, METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M o o v y L 61{ UNKNOWN ❑ REMOVECONTENTS ❑ REPLACETANK CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIRTANK ❑ REPAIRPIPING ❑ CHANGEPROCEDURE <br /> p YES ❑ NO IFYES,OATE IM OM ( 0 Sc Qr + Y ❑ OTHER <br /> yl SOURCE OF DISCHARGE TANKS ONLYICAPACITY MATERIAL CAUSE(S) <br /> ❑ TANKLEAK ® UNKNOWN SSo GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> p¢ ❑ PIPING LEAK AGE YRS ❑ STEEL <br /> `� CORROSION ® UNKNOWN <br /> O OTHER 10 UNKNOWN X1 OTHER Vn RNOVN ❑ SPILL D OTHER <br /> ywyw CHECKONEONLY <br /> ❑ UNDETERMINED SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKONEONLV <br /> c� O SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> VH � NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> Mz ❑ CAP SITE(OD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP(HU) -1❑ NO <br /> ACTION REQUIRED(NA) ❑ OTHER(01) <br /> qZ fhYl [JNTa NniKq,haM No{Ld 6�/Y\N{ \ln� V'C•wOV A1, <br /> W J <br /> NSCa("7) <br />