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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES [je NO REPORT BEEN FILED? I.HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> [-:]YES ❑ NO .:REPORTED THIS ORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORT DATE CASE* THE HZND,A YCODE r <br /> ALU/t Z 66,ke e `7 _ I/t <br /> M N o Y Y 'BIDNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SI AT RE <br /> m <br /> O REPRESENTING CO ANY OR SGENCY NAM <br /> F OWNEROPERATOR ❑ REGIONAL BOARD 4/y, <br /> R <br /> a ❑ LOCALAGENCY ❑ OTHER �+ <br /> ADDRESS /�I/' /`'1�/) <br /> �Y STATE 4•J • ZIP <br /> ME <br /> 12 eo rcl� tc ❑ UNIPDWN OD�OToDN L v chi) `1617 <br /> <9 ADDRESS NA <br /> STREET t CIfY "/ SLATE C*/ rp <br /> FACILITY NAME(IF PPUCABLE) OPEMTOR PHONE <br /> S o w <br /> AD SS /C /�I� //���� )/�� ,( <br /> �u STREEf • •C/ <br /> q CROSS STREET TYPE OF AREA ❑COMMERCIAL NWSTRIAL ❑RURAL TYPE OF BUSINESS ❑ pyL�FUEL STATION <br /> Y ❑RESIDENTIAL ❑OTHER ❑ FARM �OTHER p%Lb 'LAN <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> Fq t <br /> w- V 1 5 ( ) <br /> w REGKXNAL BOA D <br /> u PHONE <br /> INI NAME QUANTITY LOST?GUN <br /> UN(NOWN <br /> ❑ UNKNOWN <br /> k DATE DISCOVERED HOWWDISCOVERED O INVENTORY CONTROL E-]INVENTORYMONITORING ❑ NUISANCE CONDITIONS <br /> M M 1-1 Y EeDTANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN � METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Ml Ml 01 Di Yl ISI y UNKNOWN REMOVE CONTENTS ❑ REPLACETANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIRTANK ❑ REPAIRPPNG ❑ CHANGE PROCEDURE <br /> O ❑ VES ❑ NO IFYES.DATE M M .1 o v Y ❑ OTHER <br /> u� SOURCE OF DISCHARGE TANKS ONLVf�CAPACITV MATERIAL CAUSES) <br /> 'i!d'3jL( �ANKLEAK UNKNOWN <br /> GAL. ❑ FIBERGLASS <br /> _n(�//�� ❑ OVERFILL ❑ RUPTURE(FAILURE <br /> ❑ PIPING LEAK T RCC% AGE �,YRS F,.,f STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER W i ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> yWy� CHECKONEONLY <br /> 8Z UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> rg CHECKONEONLV <br /> ¢K ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ® CLEANUP INPROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> q ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED M EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAPSITE(CD) E EXCAVATE A DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) or <br /> EXCAVATE 6 TREAT(ET) ❑ PUMPB TAFATGROUNDWATER(GlD REPLACE SUPPLY IRS) <br /> ❑ TREATMENTATHOOKUP(HU) ❑ NO ACTION REQUIRED INA) ❑ OTHER(OT) <br /> H9 M(4 ]I <br />