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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCYSERVICES FOR LOCAL AGENCY USE ONLY <br /> VE <br /> ❑ YES REPORT BEEN FLED? I HEREBY CERTIFY THAT I AM❑YES ❑ NO :REPORTED THIS NFORMATIONATO LOCAL PFFICIALSDESIGNATED NPUll <br /> RSUANT TMENT AID 4THAl <br /> YEEYEE AND THAT I <br /> THE HE LTH AND SAFJTY CODE r <br /> RE,AP)ORT DATE CASE& �u-'�..aL.C.'..-t-- k �.. <br /> vM1.� M ' D lY I Y SIGNED - <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> c L L-jiavti & sm F, Itzo el6�-3 ltin;cl� A,w. R <br /> REPRESENTING ❑ OWNEWOPERATOR ❑ AEGIOAALBOARD COMPANY OR AGENCY NAME <br /> a 0 �LOCALAGENCY ❑ OTHER <br /> ADDRESS S /} <br /> P1 0, STREET aG�—Th s A2R <br /> NAME �,� �-7 CONTACT PERSON ,A PHONE <br /> y prc kE A t(/t�-zJ UNKNOWN J L (►/T' ,�- 9' ^/ P n((} jj�TJ�7-moi <br /> a ADDRESS 1 l O a�VA ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> el-p-Ar :7S s1 (249 9 -3f <br /> tj ADDRESS ✓7Z ,( I� ✓/ %� <br /> y CROSSSTREETLl W TYPE OF AREA COMMEACIAL.�DUSTRIAL ❑RURAL TYPE OF BUSINESS ❑ RETAIL FUELSTATION <br /> SI R/^j7 ❑RESIDENTIAL ❑OTHER ❑ FARM XOTHER <br /> g LOCALAGENCV AGENCY NAME CONTACTPERSON PHONE <br /> V <br /> �y REGIONAL AflD ' PHONE <br /> 111 NAME OUANTRV LOST(GALLONS) <br /> O 4 o S ❑ UNKNOWN <br /> J 7 <br /> N j (2) <br /> �— ❑ UNKNOWN <br /> DATEDISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACEMONITORNG ❑ NUISANCECONDITIONS <br /> OM M ID D �v y ❑ TANK TEST TA ❑ OTHER <br /> DATE DISCHARGE BEGAN USE TO STOPDISCHARGE(CHECK ALL THAT APPLY) <br /> ❑ UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> w M M D D V Y <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIRTANK ❑ REPAIRPIPNG ❑ CHANGE PROCEDURE <br /> ❑ YES ❑ NO IF VES,DATE M u D D y r ❑ OTHER <br /> SOURCE OF DISCHARGE TANKS ONLYr-VACITY MATERIAL CAUSE(S) <br /> ❑ TANKLEAK UNKNOWN 30O GAL. ❑ FIBERGLASS ❑ OVERFILL �❑ RUPTURE/FAILURE <br /> ❑ PIPING LEAK AGE YRS STEEL ❑ CORROSION lyl UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> �ggy CHECK ONE ONLY <br /> T3� UNDETERMINED ❑ SOILONLV ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> Hg CHECK ONE ONLY <br /> aK ❑ SITE INVESTIGATIONIN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ❑ NO ACTION TAKEN ❑ POSTCLEANAIP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATINGCLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) (( <br /> 0 ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BD DEGRADATION(TI) (� <br /> S <br /> F--] CONTAINMENT BARRIER(CB) F-1EXCAVATE&TREAT(ET) F--] PUMP&TREAT GROUNDWATER(GT) ❑ REPLACESUPPLV(RS) <br /> ❑ TREATMENTAT HOOKUP(HU) ❑ NO ACTION REWIRED MA) ❑ <br /> OTHER(OT) <br /> So�L G0/V7RM/H/ 4-r/O FrOM IiS7- elvt0✓c/ <br /> !�'�rnlieca/ fn dC rra~iAe, ✓o ✓ta�� <br /> 4� AA�✓ Z9nn'rA s+- iao^) A-S /as�c� f/� � b }G�e af'P <br /> xxoslMT <br />