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�6 ct2y <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES ND REPORTBEENFLED? ❑YES ❑ NO I HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> .REPORTED THIS INFORMATION TO L AL OFFICIALS PURSUANT TO SECTION 25180.1 OF <br /> RE�/P�/ORT/�OATE �//y CASE# 7HE 1jH.EEALL I HAND SAFTY CODE <br /> MA /�M /Y Y SIGNED X LAT E <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGNATURE <br /> O REING F-1OWNETVOPERATOR ❑ REG LBOARD COMPANY OR�AGGEENCY NAME / �/�,•/�V�// <br /> O AL <br /> PRES AGENCY ❑ OTHER <br /> Aa ,v'N . PH�L,�G,I TMJ <br /> ADDRESS P/ D 30)C <br /> oR ar 1 �ZO/�/ 1//� <br /> GfY SPATE <br /> NAME // � �J r, CONTTA�CT�PIERSON PHONE v7 <br /> mit 6;/nice/'4 �� �/C.17 /��UNKNOWN <br /> <n ADDRESS / �j� 11//``11 W /LAM {/(�� �/{��} 7 <br /> i DV BtAEEf 1 l4�• 1� CRy % BIATE ��� P <br /> FACILITY NAME(IF APPLICABLE) / OPERATOR PHONE <br /> S ✓ <br /> ADDRESS a Q MEE .4' F-✓7 Q 7 <br /> yCROSS ST ET TYPE OFAREA QCOMMERCAL❑INDUSTRIAL ❑R RAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> ffW 3 3 ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCALAGENCY AGENCY ME TACTPERSON PHONE <br /> g u /G c 6�'(2a <br /> w;y REGIONAL BOARD PHONE <br /> =Y G X36/—s66a <br /> w (t) NAME j� OUANTTTY LOST(GALLONS) <br /> 1' \ <br /> Q O I C v1, MA /NY crc Ap-&o lj-S UNKNOWN <br /> ❑ UNKNOWN <br /> t DATE DISCOVERED A HOWDISCOVERED ❑ W <br /> NTORY CONTROL ❑ SUBSURFACEMONITORG E:] R <br /> NUISANCECOtDpNS <br /> aM ZD 6 D f V O y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN � METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M D D v v I--r /UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIRTANK O REPAIRPIPING ❑ CHANGE PROCEDURE <br /> p ❑ VES ❑ NO FVEI DATE M M D D r r ❑ OTHER <br /> u� SOURCE OF DISCHARGE TANKS ONLY,CAPACITY MATERIAL CAUSES) <br /> ❑ TANK LEAK UNKNOWN l ood 000 GAL ❑ F RGLASS ❑ OVERFILL ❑ RUPTUREFALURE <br /> ❑ PIPING LEAK AGE YRS LK STEEL ❑ CORROSION ❑ UNKNOWN <br /> ❑ OTHER EVUNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> �yyy CHECK ONE ONLY <br /> L3� ❑ UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKINGWATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKON-ONLY <br /> ssSITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETEDOR UNNECESSARY) <br /> ti w ❑ NO ACTIXI TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTON(S)(SEE BACK FOR DETAILS) <br /> ❑ CAPSITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER IDS) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GIT) ❑ REPLACE SUPPLY IRS) <br /> ❑ TREATMENTATHOOKUP(HU) ❑ NO ACTION REQUIRED INA) ❑ OTHER(OT) <br /> so i L Sec m�0 Pi d"a G✓ea CO n JQM A n of 10Y- <br /> �Z) <br /> b-40.4 o) asoGina s Saye „KS *ejAlo I ori <br /> J go . .Gysez Ge ssessrn�� - !T/%LL /tee ✓"uin � /a <br /> :�hd e�cFP.t1� sF con fa A,�i:sar�T�oh <br /> SSDa6L1AD1 <br />