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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERV 'FOR LOCAL AGENCY ONLY <br /> ❑ YES &I-NO <br /> / <br /> REPORT BEEN FLED 9 ❑ IHERERV CERTIFY. T AMA S !AL <br /> ED OVERNMENT EMPLOYEE AND THAT I HAVE <br /> LI I'i3 'REPORTED THIS) 0 OF ICIALS PURSUANT 70 SECTION 25188)OF <br /> REPORTpDATE �/ CASEi THE REPORTED <br /> THIS <br /> Y D �"_. f� I4 — <br /> 0. gM ( \ s Y p Y SIGNED19 DATE 3 <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGNATURE <br /> �avtid �r1s l2dt) Yb�-3�f� <br /> a REPRESENT) ❑ OWNEiWPERATOR ❑ REGIONALBOA)O COMPANY OR AGENCY NAME 1 IL1L <br /> x LOCALAGENCY ❑ OTHER <br /> 0 <br /> ADDRESS SL-` �� �� �ISZ�I <br /> P-o. gflx 205 ` `FZP <br /> NAME CONTACT PERSONc PHONE <br /> m� Gvrw L.✓w.LaR.✓ El UNKNOWN h ` tr (2oiOI)°►v3 ��'�' 'r <br /> gADDRESS <br /> STREETm. <br /> FACILITY NAME IF APPLICABLE) OPERATOR PHONE <br /> lertrw L-..e 16e <br /> � <br /> ADDRESS <br /> 3}r CRY couK r <br /> y CROSS STREET TIPS OF AREA E]COMMERCIAL XWDUSTRIAL❑RURAL TYPE OF BUSINESS E::] RETALFUELSTATKXN <br /> 1 <br /> ❑RESIDENTIAL ❑OTHER ❑ FARM OTHER <br /> LOCALAGENCY AGENCY NA" CONTACTPERSON PHONE <br /> gm SG Soo Lccw1 ��\4� V;S�/;�r Lola v t e.Zullo. (2o't) 461-3y <br /> w <br /> w yl REGIONAL BOA // PHONE <br /> 3 C2V.�✓a 1 Vo,11e llJ o,r cl.wA �o ) (9K. ) g6(-SboO <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> $$� —/UNCNOWN <br /> t DATEDISCCOVERED HOWDISCOVERED E] INVENTORY CONTROL E] SUBSURFACE MONITORING ❑ NUISANCECOIARONS <br /> 0.19-.1 0.1 1 o a c-v irr ❑ TAW(TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN �Y METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M DI DI Yl Yl ORKNOWR ❑ REAOVECONTENTS ❑ REPLACETIWK CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIRTANK ❑ REPAIRPIPNG ❑ CHANGEPROCEDURE <br /> -p YES ❑ NO FYES.DATE 0ml YM OD I D sY YY ❑ OTHER <br /> SOURCE OF DISCHARGE TANKSONLYCAPACRY MATERIAL CAUSE(S) <br /> ❑ TANKLEAK Q UWCNOWN I IPOo GAL ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURETAILURE <br /> ❑ PIPING LEAK AGE YRS [eSTEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER O UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w CHECKONEON.Y <br /> P: 5;�t UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKONEONLY <br /> ¢K ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENTOF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U U?�No ACTION TAKEN ❑ POST CLEANUP MONRORWG IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANER ALTERNA TNES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION pn <br /> Y ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GTI ❑ REPLACESUPPLV(RS) <br /> ❑ TREATMENTATHOOKUP(Hl!) ❑ NO ACTION REQUIRED INA) ❑ OTHER(OT) <br /> 1 <br /> J <br /> NSCf (4W1 <br />