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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOA LOCAL AG Y USE ONLY <br /> ❑YES � REPoflT BEEN FILED? ❑YES M-NO IZSIDE <br /> HERETED ER NFORMA AM A.DESIGNATED OV MENT URSUANEMPLOYEE <br /> EAND ABI HAVE <br /> REPORTTDDATE �r- CASE* CEJ A USAFY <br /> oN 4M *-d 77R D y r <br /> DATE <br /> NAME OF INDIVIDUAL FILING REPORT NE SIGNATURE <br /> � �a4 -t c 6e lk ) Yb K-3 <br /> REPRESENTING ❑ OER/OPERATOR ❑ iFGIONAL BOARD COMP Ofl AG CY <br /> � LOCAL <br /> p � AGENCY ❑ OTHTHER - <br /> ¢"¢• ADDRESS -61 <br /> /T1 <br /> AO! ��T E "`- U / <br /> BTATE 2i <br /> NAME ^ I CONTACT PERSON PHONE <br /> m V V UNKNOWN ( - ) <br /> ADD <br /> oss <br /> Q &TREEf .206CRY JL- ( $fpiE `/� ! P <br /> FACILITY NAME(IFAPPLICABLE) ' OPER T PHONE <br /> ( ) <br /> Q ADDRESS ^ 4$ % <br /> Cfl05g STR SETERCNL❑INDUSTRIAL❑RURAL TYPEOFBUSINESS O RETAILFUELSTATION <br /> THER ❑ FARM XfOTHERLOCALAGENCY CONTACTPERSO` PHONEREGIONgLgppgD �� I/ 5 ('!6)3Gl�G�NALSO 'Prl'b_' PHONE <br /> q ()1 E OUANTNY EMT(GALLONS) <br /> �+ sv�✓ LIL� C,W 1�' UN(NOWN <br /> IT <br /> N V ' <br /> W-UNKNOWN <br /> W DATEDISCOVEREO // // HOWDISOOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NIISANCEODNDITIONS <br /> M N o a v E v ❑ TANKTEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN �� �� METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w N N o o v v QgyDNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK �� CLOSE TANK <br /> HAS DISCHARGE BEEN STOP PED T ❑ REPAIRTANK ❑ REPAIRPPNG ❑ CHANGEPROCEDURE <br /> O jjVES ❑ N7 IF YES,DATE 40m -3 mi 3DI I )l V`Yj 9v ❑ OTHER <br /> yyy333yyy SOURCE OF DISCHARGE TANKS ONLY�CAP ITY MATERIAL CAUSE(g) <br /> ❑ TANK LEAK UNKNOWN 6 ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUfEFAILURE <br /> ❑ PIPINGLEAK AGE YRS STEEL ❑ CORROSION .UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ E::] OTHER <br /> SPILL <br /> ywy� CHECKONEONLY <br /> A� ❑ UNDETERMINED D< SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> N� CHECKONEONLY <br /> SITE INVESTIGATK)N IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANLPINPROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CO) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BK)DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(AS) <br /> ❑ TRE'AJTMENTATHOOKUP(HU) ❑ NO ACTION REQUIRED INA) ❑ OTHER(OT) <br /> l7w-fkee si� tLFi5e--, V2h`� fir, }deA��i a .►�`f— iv 'A [De— <br /> HSC 0.'OM7; <br />