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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OFEMERGENCY BERvlc�3FpALO MAGENCYWEONLY: <br /> ❑YES w REPORT BEEN FLED 7 ❑YES NO ENO #ATIEY,:Im—IWlt'..... ` <br /> 1 7N�:.. TgFlt# 06FI,�AL3;Pi1j�IANC,[4 # <br /> . <br /> REPORTGTE CASES ^� yas G <br /> 11M Y Y Y E <br /> y.:., v. . <br /> NTAAEOFINDIVI L FILING REPORT PHONE RE <br /> 9 REPRESS OR EMTOR ❑ REGIONAL 80ARD <br /> LOCAL AGENCY OTHER <br /> if <br /> ESS <br /> R` L� 81117E m <br /> uJ / ❑ I.NIMOWN ('QNTACT tCf/�W '�A� PHONE <br /> m€ <br /> n ADDRESS <br /> Z6 Z a <br /> . <br /> lA7€ v <br /> FAC ITV NAME(IF APPLCABLE) OPERATOR HONE <br /> ADDRESS <br /> STFW <br /> SS STREET TYPE OF AREA ❑COMMERCIAL❑NWSTRNL RURAL TYPE OFA E] RETAIL FUELSTATION <br /> ❑RESIDENTIAL ❑OTHER ❑ FARM ®C OTHER <br /> L� <br /> LOCVGPNCY AGENCY NAME ACfPERSON PHONE <br /> �!k REGIONAL BOARD <br /> YY PHONE <br /> w L11 NAM QUANTITY LOST(/GAALLONSS)) <br /> ❑ UNMOWN <br /> GTE DISCOVERED HOW DISCOVERED ❑ <br /> NTORy CONTROL ❑ SUBSURFACE MONITORING E] NUISANCECONNTIONS <br /> M --oDIy ❑ TANK TEST �REMOVAL [:] OTHER <br /> GTE OISCADB <br /> METHOD USED TO STOP DISCHARGE(CHECK ALL TIATAPPLY) <br /> u u .11 '1 Y ffj�UNKNOWN ❑ REMOVECONTENTS ❑ REPLACETANK CLOSE TANK <br /> Q HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIRPPNG ❑ CHANGE PROCEDURE <br /> p YES ❑ NO IFYES.GTE u y r ❑ OTHER <br /> u� SOURCE OF DISCHARGE TANKS ONLYCAPACITY MATERIAL CAUSE(s) <br /> ❑ TANK LEAK ��UNKNOWN _GAL, ❑ FIBERGLASS <br /> ❑ OVERFILL ❑ RUPTUREIFAILURE <br /> Ua ❑ PIPING LEAK AGE YRS ��TEEL ❑ CORROSION � UWNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> wCHECK ONE ONLY <br /> Uit' F-1UNDETERMINEDSOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F, CHECKONEONLY <br /> zm <br /> a i SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> uw ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ N)FUNSAVALABLETOPROCEED ❑ EVALUATNGCLEANLPALTERNATNES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> a ❑ CAP SITE(CD) ❑ E%GVATE 6 DISPOSE(ED) _] REMOVE FREE PRODUCT(FP) ❑ ENHANCED BK)DEGRADATION(11) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP A TREAT GROUNDWATER(OT) ❑ REPLACESLPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(IAU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> m <br /> �0 p, <br /> ��(A� <br />