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ir nn ro)v <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONT INA ION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES P1O REPORT BEEN FILED 7 ❑ YES ❑ NO I.HEREBY CERTIFY THAT I AM A.DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> :REPORTED THIS.INFORMATION..TO LOCALOFFICIALSPURSUANT TO SECTION`251807 OF <br /> REPORTDATE^^ ^^ Q CASE# THE HEALTH AND SOFTY CODE <br /> OMI O M OA Dx 0 FYI YSKSNEO / DATE <br /> � 1 <br /> NAME OF INDIVIDUAL FILING REPORT PHONE I SIGNATURE <br /> 2n e, I eU s 5 P49)` f, 3`fa0 <br /> REPRESENTING ❑ OWNEIVOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> �(� <br /> p LOCALAGENCV F7 OTHER Va�LVOCL U-1 k% I `IS_EHD <br /> ¢ ADDRESS <br /> f�U, 73G20o9�EET 5-�oc/�.4 <br /> NAME DRV STATE ZIP <br /> ,JCONTACT PERSON PHONE <br /> lbw+oZYl�es,�lY)QNY Q ❑ UNKNOWN �UyI`er i�rana (�09) <br /> O <br /> R /ADORESS <br /> V Y <br /> FACILITY NAME(IF APPLICABLL EI DRY SPATE ZIPOPERATOR PHONE <br /> a ADDRESS „^_ �� -r <br /> qa 3 A , GC�6 1 on1 v cu h <br /> CDUNTY 5�0�. P <br /> h CROSS STREET TYPE OF AREA ❑COMMERCIAL INDUSTRIAL RURAL TYPEOF BUSINESS R <br /> F 2mo 7J+ ❑RESIDENTIA OTHER ❑ ❑ E'T'A,I_I(_FUEL STATION <br /> ❑ ❑ FARM OTHER e•TK.IV IQ�I. <br /> h LOCALAGGEENNCY //� �jJ [' AGENCY NAME 00 TACT PERSON <br /> �Yt VOQ U.�YI lfJ I 14 J �'�� ! PHONE <br /> w REGIONAL BOARD <br /> a¢ PHONE <br /> E <br /> ( ) <br /> U O NAME QUANTITY LOST(GALLONS) <br /> L qcL oI ins <br /> UNKNOWN <br /> N <br /> ❑ UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCECONDITgN4 <br /> w <br /> O M M D D <br /> FYI 6 y ❑ TANK TEST 4 TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> 'i <br /> M 'Al 0 D Y Y UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK E] CLOSE TANK <br /> j <br /> q HAS DISCHARGE BEEN STOPPED? ❑ REPAIRTANK ❑ REPAIRPPWG <br /> M ❑ CHANGE PROCEDURE <br /> o si VES ❑ NO IF VES,DATE M 5M o D r y Ify OTHER -J&ft K, n / <br /> w SOURCE OF DISCHARGE <br /> TANKS ONLYA:APACITY ( J <br /> . MATERIAL <br /> ,4$ ❑ TANK LEAK UNKNOWN GAL ❑ FIBERGLASS O CAUSES OVERFILL ❑ RUPTUREFAILURE <br /> ❑ PIPING LEAK YYY------"' AGE YRS ❑ STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL —] OTHER <br /> w w CHECK ONE ONLY <br /> a <br /> o� ❑ UNDETERMINED SOILONLY ❑ GROUNDWATER ❑ DRINKWGWATER. (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F, CHECK ONE ONLY <br /> z� <br /> a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U'� ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> clz ❑ CAP SITE(CD) <br /> 00 ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT IFP) ❑ ENHANCED BIODEGRADATION(rn <br /> ¢� ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED INA) OTHER(OT) <br /> TfL �� <br /> i - lz� Cca n e ao na��1 r�c Q Q /1Q, <br /> � ��quv_etQ •Go >�� .2 �YVl.�ct.�,e.. �.d P.LL�`l' � ce1YL�,.t.u,�,Tn�e�ce`1� <br />