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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES `FOR LOCAL AGENCYUSE ONLY <br /> ❑ YES Q NO REPORT BEEN FILED T ❑ YES J� NO 1 HEREBY CERTIFYTHAT I HAA DISTRIBUTED THIS o o ACCORDWGTOTHE <br /> DIST TION SHOW ION SHEET ON THE BACK PAGE OF IS FOR <br /> REPORT DATE CASE• <br /> /]/�� <br /> off i y a d 9 � . o E g <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> DA�/71 �i9T/ Pc7],� Fila ) <br /> z, .2-6 <br /> 97- fl <br /> w REPRESENTING OWNER•OPERATOR ❑ REGK)NALBOARO FCOMPANY�OR AGENCY NAME <br /> S ❑ LOCAL AGENCY OTHER / q 7�f may, l'v� ��lz( � oalpq <br /> I�� 03 �/iC"� l/f e9f 907502--,W3 <br /> V �•7 " Aeu CT' STATE 21R <br /> w NAME A T <br /> /1 CONTTWTT PERSON % PHONE <br /> �"Du E:] UNKNOWN S* ,Oto/z\/z\ (N0)#7- ' <br /> O hADDRESS 0. G o 3a 47fr&--.!;4 9070 9-Go. / <br /> 8TREEf CRY STATE IP <br /> FACILITY NAME(IF APPLICABLE) Op I / PHONE � <br /> Z <br /> OADDRESS / rt 70 <br /> w fN srURE'ET cm <br /> y CROSS STREET wVrm nP <br /> i LOCAL AS CY AGENCY NAME CONTACT PERSON ��� f--sC(�a( PH NE <br /> P: <br /> Tau rN 3 <br /> wU <br /> REGIONAL BOARD PHONE <br /> w (�) NAME QUANTITY LOST(GALLONS) <br /> 0 <br /> a� �"� L/�� ❑ UNKNOWN <br /> m W <br /> y- ( <br /> ❑ UNKNOWN <br /> i DATE DISCOVEREDh/ HOW DISCOVERED ❑ INVENTORY CONTROL E] SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Oyi / y / V p Y ❑ TANK TEST ❑ TANK REMOVAL © OTHER ill S-"'hl— O <br /> m DATE DISCHARGE BEGAN MET HOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) W <br /> O lml •/ /9 Y,3 v ❑ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK a REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED T ❑REPAIR TANK ❑CLOSE TAN�Kya FILL IN PUCE PCHANGE PROCEDURE <br /> o VES ❑ NO IF YES,DATE 3Y ❑REPLACE TANK OTHER Sr/v/I QOLtI,�/ L/NGS <br /> SOURCE OF DISCHARGE M CAUSE(S) �Hg�l <br /> a ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL RUPTURE/FAILURE SPILL <br /> � rLL�.D <br /> yO F-1h <br /> PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN [OTHER -Ajkw <br /> mn CHECK ONE ONLY oao 7v pos F/9 AZy <br /> F-1UNDETERMINED ❑ SOIL ONLY EDGROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w� ❑ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> �y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U <br /> ❑ REMEDIATION PLAN [a CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE,EDI ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> <0 <br /> w O ❑ CAP SITE(CD)) ❑ EXCAVATE a TREAT(ET) ❑ PUMP a TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ¢a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENTATHOOKUP(HU) ❑ VENTSOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) 0 OTHER(OT) Cf�Ey cJ/�JASSpt!,g67yT rye/ �1S <br /> Y <br /> JAN 2 8 1993 <br /> L, Yl r 1S77C- 17eed <br /> PERMIT/SERVICES <br />