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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ <br /> YES NO REPoRT BEEN FILED? DYES ❑ N10 I HEREBY CERTIFY THAT I AM A. VE <br /> REPORTED THS INFORMATION TO LIOCAL OFF)) LSGNATED P PURSUANT MENT TO SECTION 251807YEE AND THAT I AOF <br /> REPORTDATE CASE* THE HEAT ANDSAAFiY CODE. �z /A , /�y <// <br /> 9 ttff f�M- /(� 4G 6 7 <br /> ,M M O Y I Y SIGNED � V � <br /> NAME OF INDIVIDUAL FILING REPORT HONE SIGNATURE <br /> (.�-! A M R SniR vG1 ( wZIZ y2 �-- <br /> REPRESENTING ❑ OWNEiVOPERATOR ❑ (AGI �Al'lAPA1NY ORAGENCY NAMEOLOCALAGENCY ❑ OTHER IAV IC/ —C S4W)6f�4PS 47 <br /> ADDRESSV <br /> l 0)( V 1 S�O CRY BfATETE ZIP <br /> NAME CONTACTPERSON �PHONE <br /> T y UNKNOWN/ <br /> ADDRESS C i//�/5 ,L� 2c( c <br /> OOAWif // �0D L'�7EET CRY/ 1 RATE 21P <br /> R FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS / <br /> Q 3 <br /> ,&_ <br /> &_00 *REE f�/2(S/V(�/ /Lr./ RY �il�t Gly— 7P <br /> R5 CROSS STREET . TYPE OF AREA QCOMMERCIAL INDUSTRIAL❑RURAL TYPE OF BUSINESS E::] RETAIL FUEL STATION <br /> 4/�1I� I ❑RESIDENTIAL ❑OTHER ❑ FARM O OTHER <br /> 2. kALAGENCY SRA/ " ,NiN�N NTACTPERSON PHONE <br /> I,LI REGIONALfIDV/2�ep c13 PHONE <br /> YY G 6) 36�S66 L9 <br /> (I) NAME QUANTITY LOST(GALLONS) <br /> �/L ✓(^- V G for4 60 N S ❑ UNKNOWN <br /> - ❑ UNKNOWN <br /> b DATE DISCOVERED HOWDISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDTTONS <br /> /Ml M '&DI o 9,11 Y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THATAPPLY) <br /> w M M ol 01 Yl Yi UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSETANK <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIRTANK ❑ REPAIRPIPING ❑ (YWNKNE PROCEDURE <br /> p ❑ YES ❑ NO IFYES,DATE u M .1 o Y v ❑ OTHER <br /> w SOURCE OF DISCHARGE TANKS ONLWCAPAC_ITY/ MATERIAL �EAA66LLAA55 CAUSE(S) <br /> ❑ TANK LEAK �UNKNOWN Q 0' WN GAL. ❑ FI S ❑ OVERFILL ❑ RUPTUEiFAILURE <br /> Q � PIPING LEAK AGE YRS STEEL ❑ CORROSION �UMNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> gwgw CHECKO NLY <br /> 13� UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F*� CHECK ONE ONLY <br /> Q` ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> uy ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATINGCLEANUPALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 3 ❑ CAP SITE(CD) F--1EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) O ENHANCED BIO DEGRADATION(IT) <br /> wt� ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE6 TREAT(ET) 9[JMP&TREAT GROUNDWATER(BIT) flEPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) OTHER(On <br /> Coni <s w io ed. b y �.� w pp vv roe X* �r-�^ ' <br />