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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICE <br />❑YES �O REFogTBEENFILED 7 FOR LOCALAGENCI IIs: C LY <br />❑YES NO 1 HEREBY CERTIFYTHAT.I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br />REPORT OATS ., n DI IBUT <br />CASEa STA KX-f SHOWN ON THE WSTRUCTON SHEETON THF R ru PAID Imo. <br />HS W (E <br />M1,540 <br />NAMEOF INDIVIDUAL FILINOq PORT SICKED <br />m <br />T' PHONE DATE <br />w <br />¢ <br />REPRESEN G ❑ <br />OWNEROPERATOq ❑ REGIONABO(ARD�r— <br />COMPANY OR AGENCY NAM <br />it <br />LOCAL AGENCY ❑ OTHER ['C <br />� <br />ADDRESS <br />W`f�/l <br />67 <br />STREET �(? <br />NAME 01 <br />ISG WApHONE <br />m� <br />�/ CONTACT PERSON nv <br />y i <br />❑ UNKNOWN (zrl J 937-8 -16 <br />ADDRESS <br />¢ <br />L <br />3US JV <br />STREET (iL�L( / �7 <br />ACI_NAME(IF APPLICABLE) em z%d�'1 sTAM <br />OPERATOR <br />O <br />//Z 3 PHONE <br />r <br />O <br />ADDRESS ( J <br />`�� <br />� <br />w <br />r <br />m <br />J STREEi q <br />�acQrsm ) <br />Cm CROSS STREET I+T✓ J_C /SZOZ <br />IP <br />Le- <br />i m;FIEGIONAL <br />GENCY AGENCY NAME CONTACT PERSON <br />i w <br />PHONE <br />wU <br />w� <br />BOARD ( J <br />PHONE <br />( J <br />y <br />w <br />/ <br />/ NAME QUANTITY LOST (GALLONS) <br />L %O <br />�4t ',✓Vpd>` UNKNOWN <br />m0 <br />(2) <br />N <br />❑ UNKNOWN <br />= <br />DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL. ❑ SUBSURFACE MONITORINpG NUISANCE CONDITIONS <br />.�� <br />Y o Q Y L Y ❑ TANK TEST ❑ TANK REMOVAL OTHER ILilCR I/H LIJ-x/ <br />a <br />aMETHOD <br />DATE DISCHARGE BEGAN <br />USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />W <br />D Y UNKNOWN <br />❑ REMOVE CONTENTS ❑ CLOSE TANK& REMOVE ❑ REPAIR PIPING <br />a <br />❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED 7 <br />U <br />5 <br />❑ YES ❑ NO IF YES, DATE J <br />❑ REPLACE TANK ❑ OTHER <br />n Y Y <br />SOURCE 9F DISCHARGE <br />CAUSE(S) <br />¢ j <br />rLV�J/TANK LEAK ❑ UMDJOWN <br />❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br />wO <br />El PIPING LEAK ❑ OTHER <br />1 ,� 11 <br />❑ CORROSION ❑ UNKNOWN OTHER 01041; <br />N6w <br />CHECKONE ONLY <br />V <br />❑ UNDETERMINED SOL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />z� <br />❑ NO ACTION TA KEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBM I O POLLUTION CHARACTERIZATION <br />�y <br />❑ LEAK BEING CONFIRMED a PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />O <br />REMEDIATION PLAN CASE CLOSED CLEANUP COMPLETED OR <br />❑ ❑ ( UNNECESSARY) CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTION(S) E%CAVATEB DISPOSE <br />iS�ewxrol xTuel (ED) REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <br />a <br />50 <br />w� <br />❑ CAP SITE (CO) ❑ EXCAVATE &TREAT (ET/ ❑ PUMP &TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />¢a <br />❑ CONTAINMENT BARRIER (CS) ❑ NOACTK)NREOUIREDINA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENTSOIL(VS) <br />❑ VACUUM EXTRACT(VE)❑ OTHER ((001)) <br />Z <br />� <br />HS W (E <br />