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r ! <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> ❑ YES NO REPORT BEEN FILED? <br /> E::]YES No RHEREBY <br /> I H REBY CERTIFY C AT tE o SI TED GOVERNMENT EMPLOYEE AND THAT(HAVE <br /> REPORT DATE ❑ PORTED THIS 1 ATi O <br /> p CASE# THE HEALTH AND Y L OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> �M Z M o D Z D O y p y <br /> SIGNED, � � <br /> NAME OF INDIVIDUAL FILING REPORT <br /> DPHONE SIGNATU DATE,-,-::.x <br /> co <br /> > avjdr�s (Zook) '4 3 yYo <br /> o REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> N <br /> p LOCAL AGENCY ❑ OTHER L o <br /> :S. l JJ <br /> ADDRESS , „i+. L, 4 <br /> Cc ( �a D+S c l <br /> i("L,I r--. 0a <br /> CITY •`S2J <br /> � NAME + 20 STREET STATE ZIP <br /> 'T T7CO7N6T7ACT PT PHONE <br /> iQ Soh y,.c, ❑ UNKNOWN Ahroa✓ <br /> ga ADDRESS (�9) B3S- `/R31 <br /> IL <br /> STREET I CITY <br /> FACILITY NAME(IF APPLICABLE) STATE ZIP <br /> n _ OPERATOR <br /> z0 ►'t �2 j c�C✓fi S SoN .L✓�t. D PHONE <br /> a ADDRESS DAr U^✓)J¢f (ZSR) ��5^qq <br /> STREET CL-% o <br /> +n CROSS STREETOrr COUNTY ZIP <br /> ❑COMMERCIAL X INDUSTRIAL ID RURAL TYPE OF BUSINESS ❑ v <br /> L,j v�+1 2.._ TYPE OF AREA RETAIL FUEL STATION <br /> LOCAL AGENCY <br /> ❑RESIDENTIAL [:]OTHER a �J FARM OTHER ^(„oA,- I1kAyfi <br /> AGENCY NAME CONT CT PERSON <br /> z w "� { PHONE <br /> w -� �1oy vih Lote.� IIC� IT� �lS{vicl o�V+ d Gw✓15 <br /> w REGIONAL BOARD 1 (204) l{(odr-3 S(�(O <br /> PHONE <br /> G o✓c�oti s (4l6 ) 3(.I-S6 00 <br /> (t) NAME <br /> cw)ow QUANTITY LOST(GALLONS) <br /> 0 (2) UNKNOWN <br /> cl) ` <br /> Olt e')tvu��v,,,., � d✓o[..„n ova UNKNOWN <br /> w GATE DISCOVERED HOW DISCOVERED <br /> ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> OM 3 M D ZD y y ❑ TANK TEST X1 TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> tr <br /> .11> ❑ <br /> M M D D y y UNKNOWN REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIR PIPING <br /> REPAIR TANK CHANGE PROCEDURE <br /> o YES ❑ NO IF YES,DATE ❑ OTHER <br /> ++ M D D y y <br /> y SOURCE OF DISCHARGE TANKS ONLY/CAPACITY <br /> � MATERIAL =CAUSE(S) <br /> TANK LEAK UNKNOWN GAL. ❑ FIBERGLASS <br /> `�G�, ❑ RUPTURE/FAILURE <br /> PIPING LEAK AGE YRS ❑ STEEL UNKNOWN <br /> 2 ❑ OTHER UNKNOWN ❑ OTHER <br /> OTHER <br /> Lu w CHECK ONE ONLY <br /> a <br /> U ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> zco <br /> cr a LEY � SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> I- <br /> U ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> oO ❑ CAP SITE(CD) EXCAVATE&DISPOSE ED <br /> w ❑ ( ) E:] REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER G <br /> ❑ ( T) ❑ REPLACE SUPPLY IRS) <br /> TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> Tam <br /> w _0.,y G.rtctl <br /> o� <br /> U <br /> HSC 05(4/87) <br />