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VaL72 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICW FOR.LOCAL'AGENCY USE ONLY : <br /> REPORT BEEN FILED? <br /> ❑YES NO ❑YES NO I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> -- DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE CASEi <br /> MI DM /I� R -Z SIGNED DATE <br /> NAME OF INDIV&I FILING REPORT PHONE SIGNATURE <br /> REPRESENTING ❑ OWNERK)PERATOR ❑ REGIONALBOARD COMPANY <br /> OR <br /> AGENCY NAM /J T <br /> SCALAGENCY ❑ OTHER <br /> 2�CO <br /> ¢ ADD SS �/1 r'�/� /p' /p�{' /�]/r <br /> r • 9,oK 2, O� C e- � f , 3 AW SIP <br /> w NAM 1_ CONTACTPERRRSSON /y,/, /PHHO{,N/EE <br /> i Q h 6G ❑ UNKNOWN 0 'Ci ot I /5L <br /> it ay ADDRESS •IN• An/�'( T//'/y/� //� ,y/�/�� �2J n <br /> ¢ 9TREU '� ` •\ a CT' ✓I • 15.ST111E 7<0lip <br /> FACILI AME(IF APPLICABLE)` OPERATOW PHONE (l <br /> c. opc <br /> a <br /> ADDRESS g', <br /> ./y� <br /> 315- •L/rREET/� • W GiIP • / v / COV • P 1 p <br /> y CROSS STREET v <br /> 52s� <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON, PPHH/O�NNEE/'/y���.//��,([� <br /> I REG GR •\ &.� rlLvQ PHONE <br /> y (1) NAME QUANTITY LOST(GALLONS <br /> wp �� / <br /> a> I V 1/l r UNKNOWN <br /> O RI <br /> N Z <br /> ❑ UNKNOWN <br /> i DATE DISCOVERID HOW DISCOVERED ❑ INVENTORY CONTROL E:] SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> a r r DATE DISCHARGE BEGAN ❑ TANK TEST TANK METOTHER <br /> HOD USED TO STOP DISC14ARGE(CHECK ALL THAT APPLY) <br /> w M <br /> Di Yi r <br /> ' UNKNOWN ❑REMOVE CONTENTS-kCLOSE TANK&REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED? v ❑REPAIR TANK ❑CLOSE TANK&FILL IN PUCE ❑CHANGE PROCEDURE <br /> a <br /> jkrYES E::] NO IF VES,DATE MI .1 <br /> (pdO r r ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢j ❑ TANK LEAK 4� UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> a <br /> y O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION �UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONE ONLY �—y/_ <br /> ri y <br /> F-1 NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED Ad rOLLUTION CHARACTERIZATION <br /> ¢Z IrI <br /> jy ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(17) <br /> 4 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ~ ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED INA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENTSOIL(VS) <br /> wa <br /> ❑ VACUUM EXTRACT NEI ❑ OTHER(OT) <br /> w i s dip 1 c.Oo u" ber`r1�-� a6 We W6 <br /> s WrIIZ6�G --10 I OCare, C 9r nc I U It(2 <br /> HSC a5169q <br />