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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FORLOCALAGENCYUSEON{.Y <br /> REPORT BEEN FLED Z <br /> ❑ <br /> YES ❑YES ❑ NO I HMM CERTIFY-rMT i AM A%SKiN m OOMIINWgt EMPLOYEE WWI i HAVE <br /> WORM THIS WORMATION T6 LOCAL CFF uts F1IRSUANTTO SECTION 251807 OF <br /> REPORTDATE Q o CASE• THE HEALTH ANO - CODE <br /> 2m 0 { O v g v SgNEO BATE. <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGNATURE <br /> R�lel R.-S, ( g-3qtjlG✓ - /p <br /> REPRESENTING ❑ OWI RAOPERATOR REGIONAL BOARD COMPANYOR AGENCf NAME <br /> Q LOCAL AGENCY ❑ OTHER L� -At—r } P I s-i Zu c- 7 <br /> ADDRESS <br /> Ro l Z 0 V B EET /A Li((/l 0 /(!VM1/DI_ WATE <br /> � NAMEr / /oU � CONNTAAC/TPPERRS'ON PHONE - <br /> 6 J � (JIB /I❑ UNKNOWN <br /> y ADDRESS <br /> c t7a A" G9 9SZG <br /> �^ WATE P <br /> FACILITY NAME IF APPLICABLE) PHONE <br /> VC o Fat P N E ln/ �oUAeN O TGR KGs . Keg <br /> 11i F4' ADDRESS /' ��J �/�A C //�� ��µ/— p J' / <br /> 2-15,0 w� t�� '-/L- V"1 ' cm, J�C��{L w / 1 —7' 'T 1 J .L✓ <br /> q CROSS STREET TYPE OF AREA ❑CAMMERCWI❑INWSTRIAL ❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> L e i f " ❑ <br /> RESIDENTIAL ❑OTHER ❑ FARM .OTHER <br /> LOCALAOENCY AGENCY NAME CONTACTPERSON PHONE <br /> J" N L. ,� IJ s� L iPclNei Co u L L Pt R 63y 2A I <br /> y REGIONAL BOARD PHONE -5,X0 <br /> a V2coG9 Gondrm 90 S <br /> o NAME QUANTITY LOST(GALLONS) <br /> [1[J <br /> r (2) UNKNOWN <br /> UNKNOWN <br /> DATE D_I vE�RED <br /> O D Dv r IgW❑DISOOVERED <br /> E] INVENTORY CONTROL ❑ SUBSURFACE MONITORND ❑ NUISANCE CONDITIONS <br /> M M / TAMC TEST TANK REMOVAL E:] OT/ER <br /> K DATE DISCHARGE BEGAN pp�, METHOD USED TO STOP DISCHARGE(CHECK ALL TIUT APPLY) <br /> • w N N o o r v LII``AI UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED 9 ❑ REPAIRTANK ❑ REPAIRPPING CHANGE PROCEDURE <br /> p YES ❑ NO F VES,DATEQ 8 OTHER - <br /> N 2p P '17, ❑ <br /> t� SOURCE OF DISCHARGE T✓KSONIy'APACITY MATERIAL CAUSE(S) <br /> ❑ TANKLEAK 9 UNKNOWN ')7DO!) GAL, ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREFALURE <br /> ❑ PIPINGLEAK AGE YRS STEEL ❑ CORROSION ❑ UNKNOWN <br /> ❑ OTHER NKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> yW CHECK ONE ONLY <br /> cZ� ❑ UNDETERMINED ❑ SOILONLY GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> SITE WVESTIGATK7N IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS E:] SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> t�`A ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANLY ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ EN WINCED BIODEGRADATION(IT) <br /> 2 ❑ CDNTAINMENTBARRIER(CB) ❑ EXCAVATE&TREAT(ET) TR <br /> PUMP& EAT GROUNDWATER <br /> ❑ (GTI ❑ REPLACE SIYPLV(RS) <br /> ❑ TREATMENTAT HOOKUP OM" ❑ NOACTKXNREOUIRED(NA) ❑ OTHER(OT) <br /> � OuD <br /> IroC06HM <br />