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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT <br /> EMERGENCYHAS STATE OFFICE OF EMERGE SERVICES FORLOCALAGENCY USEONLY <br /> 1:1 YES ' REPORTBEENFLED9 YES ❑ I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> NO :REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 251007 OF <br /> REPORTDATE a,-+� 9 CASES THE HEALTH AND Sf�FfY D /,,. .1� 7�. <br /> DN �M J 8r / Y SIGN 7s`L/— t.,J TE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATU E <br /> T� .eoto )�fbb'- <br /> m COMPANY AGENCY NAME <br /> w REPRESS ❑ OWNEFYOPERATOR ❑ REGIONALBOARD <br /> O LOCALAGENCY ❑ OTHER jag <br /> a <br /> ADDRESS �/�.f O n syo/K/// _ MATE ZIP <br /> NAME c <br /> CONTACT PERSON PHONE <br /> E] UNKNOWN �6i4 _9�a 1 <br /> AD�o ' S <br /> SQUz�n CR <br /> r I 9lRE� LRr SPATE 9P <br /> FACILITY NAME(F APPLICABLE) OPERATOR PHONE <br /> ADDRESS ��,^ c7 i�-r 93a 05 <br /> 3 � s� Dh�OL� S�c�RrlV• � CO KY <br /> yCROSS STREET TYPE OF AREA COMMERCIAL ❑INDUSTRIAL❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> ,)F./Hv4 Q RESIDENTIAL ❑OTHER ❑ FARM 124HER ANO <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> FFm r ( ) <br /> W <br /> REGIONAL BOARD PHONE <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> q ❑ UNMOWN <br /> m <br /> - ❑ <br /> UNKNOWN <br /> I- DATE DISCOVERED NDW DISCOVERED ❑ INVENTORYCONTROL ❑ 3 BSURFACE M/gNITORNG NUISANCE OONDITq <br /> �M M Ao o ?v v ❑ TANK TEST TANK REMOVAL OTHER /_ 2e&Sn._P PS / Z� <br /> DATE DISCHARGE BEGAN METHOD ED TO STOP DISCHARGE(CHECK ALL THATAPPL' <br /> �IBO <br /> .)OWN METHOD <br /> ❑ REPLACE TANK CLOSE TANK <br /> w <br /> MI M Di DI Yl v <br /> HASD YES E::]RGE NO ES,DATE O N M / D o " r ❑ OTHER- r Lj TANK E] REPAIRPPNG ❑ CHANGEPROCEDURE <br /> u� SOURCEOF DISCHARGE TANKS ONLV/CAPACITY MATERIAL CAUSES) <br /> ❑ TANK LEAK �U/UNKNOWN GAL• ,❑,/FIBERGLASS E] OVERFILL OVERFILL ❑ RIPTUR <br /> F-1PIPINGLEAK AGE,__YRS {/ STEEL ❑ CORROSION Ye-UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w lu CHECK ONE ONLY <br /> ❑ UNDETERMINED cz SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER (CHECK ONLY P WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKON <br /> zLY <br /> n <br /> SITE NVESTIGATK)N IN PROGRESS(DEFINING EXTENT OF PROBLEAry ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U� ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 0 <br /> ❑ CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BID DEGRADATION(IT) <br /> 1� ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATEA TREAT(ET) ❑ PUMPA4 TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ <br /> TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(N!V ❑ OTHER(01) <br /> q2%al,q S Z`�a6 'ljw&u /��t2hQ�fJ o cS i iii tom. <br /> -FUAZt i s' Q ess <br /> K <br /> K..�,L1 SC OSIM9T <br />