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r 0 <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />FOR LOCAL AGENCY USE ONLY <br />❑ REPORT BEEN FILED? ❑YES ❑ NO <br />VES NO <br />REPORTTED HEREBY CERTIFYEMPLOYEE AND TB07AOF <br />RIS ATOIOCAL <br />NEORMATI OFFICIALSIGNATED PURSUANT URSUANT TO SECTION 25MENT <br />THE HEA AN <br />DATE <br />REPORT DATE CASE# <br />QM SN O Z g'Y a <br />D <br />p Y <br />NAME OF INDIVIDUAL FILING REPORT <br />PHO <br />SIGNATOR <br />�jaV,A C�Nls <br />(Zay) q6f-3Vuo <br />REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONALSOARD <br />COMPANY OR AGENCY NAME <br />LOCALAGENCY ❑ OTHER <br />S. - <br />A REBS <br />P_O, �aY�a �bdl F_. t�a$cli�� s Cis Lol <br />3 EEi OTY STATE ZIP <br />J <br />NAME j� <br />vQ��C <br />CONTACTPERSON PHONE <br />GIQv� AQhk� :Sy-2'3oj <br />iQ <br />11/, IGLowGNi ❑ UNKNOWN <br />(ZOpI) <br />S a <br />ADDRESS <br />��Z�� tiow�ua . -��P✓� �� A <br />ET CT' STATE p <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR PHONE <br />!! <br />ADDRESS <br />CITY�� <br />wCROSS <br />STREET <br />TYPE OF AREA ❑COMMERCIAL INDUSTRIAL ❑ RURAL <br />TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br />K,IC R V4 l <br />❑ RESIGENTIAL ❑ OTHER <br />❑ FARM OTHER <br />LOCALAGENCY AGENCY NAME <br />CONTACTPERSON <br />PHONE <br />REGIONAL <br />PHON <br />E)3�.�^S <br />�.T✓�I VSI�P <br />w <br />(1) NAME QUANTITY LOST (GALLONS) <br />UNKNOWN <br />2 O <br />(2) <br />w <br />1 <br />Rt'�vu1G✓--� awGUNKNOWN <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ INVENTORYCONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />C>I 7M Z-.�Di YslY 3-Y <br />❑ TANKTEST TANKREMOVAL ❑ OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />w <br />M M o o y y UNKNOWN <br />❑ REMOVECONTENTS ❑ REPLACETANK CLOSE TANK <br />Q <br />❑ REPAIRTANK ❑ REPAIRPIPING ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED 7 <br />o <br />Y YES ❑ NO IFVES,DATE OM ZN 7-.1 s �Y +-Y <br />❑ OTHER <br />oI <br />LLI <br />N <br />SOURCE OF DISCHARG,,�E�------yyyy��T� <br />TANKS ONLYA:APACITY MATERIAL <br />CAUSE(S) <br />❑ TANK LEAK UNKNOWN <br />GAL. ❑ FIBERGLASS <br />❑ OVERFILL RUPTUREIFAILURE <br />O¢ <br />❑ PIPING LEAK T <br />AGE YRS ❑ STEEL <br />I❑ <br />❑ CORROSION IxI UNKNOWN <br />❑ OTHER <br />UNKNOWN OTHER lrekNo,.,.h <br />❑ SPILL ❑ OTHER <br />ww <br />CHECKONEONLY <br />ti� <br />❑ UNDETERMINED ❑ SOILONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />F N <br />CHECK ONE ONLY <br />Z <br />W <br />a <br />SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />UN <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 />�z <br />❑ CAP SITE (CD) ❑ EXCAVATE 6 DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (17) <br />❑ CONTAINMENT BARRIER IDS) ❑ EXCAVATE& TREAT(EIR ❑ PUMP& TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br />TREATMENT AT HOOKUP (HU) ❑ NO ACTION REQUIREDINA) ❑ OTHER (OT) <br />/-�1 <br />11 <br />C�Vr,Mr, A' - vca ,V,`. <br />�WroP L,r �c�lccQ 2�Zs(f��- J\ <br />SSC MI4W) <br />