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0 <br />7,tll(cvo <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />' FOR LOCA AGENCY USE ONLY <br />REPORT BEEN FILED? <br />VES NO VES NO <br />❑ ❑ <br />1 HEREBY CERTIFYTHATI HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br />IBUTI SHOWN E1 LOT SHEEP ON KPAGE OF THIJ FOR <br />R <br />ORT DATE <br />CASE <br />D <br />M M ✓ y <br />NED DAT <br />N E OF INDIVIDUAL FILI� EPORT � <br />PHONE <br />w <br />REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONALBOARD <br />COMPANY R AGENOY NAME C /� <br />•(�� <br />pLOCALAGENCV <br />❑ OTHER <br />U//I y/ <br />¢ <br />ADDRESS F- u,66/3 9 <br />ES-T STAT <br />w <br />NAM �I/!n <br />CONT TPERSON <br />^/�,�J/�/J�{L{I �PHHHOO�NNEE/7�� �/�}/�% (//�/ / <br />z <br />zm <br />/ I C. ❑ UNKNOWN <br />4!W/l&4 <br />i 4 P /l Yom/ /' /V!i'(/!/y! <br />O < <br />W <br />N�ys <br />ADDRESS <br />5933 <br />CITY STATE <br />FACILITY NAME (IF APPLI ABLE) <br />OPERATOR PHONE <br />In A <br />{7 <br />c I <br />z <br />0 <br />� <br />O <br />w <br />4r,,, CRY �I,I�AVI �/ ✓' • , C�OU�N/Tl'� �//I ZIP % <br />h <br />CRO 5 TQQRE//ET ,'/'d <br />rW <br />LOCAL AGENCY AGENCY NAME <br />CT PERSON <br />PHONE <br />z - <br />w <br />� � <br />/C9NT <br />� / <br />w w <br />a <br />RE NAL BOA <br />CC -AJ MALA IIA <br />�A <br />PHONE <br />�Y(o )Zs5 3!3 <br />t/avaE <br />N <br />(1) NAME QUANTITY LOST (GALLONS) <br />�/� e <br />UNKNOWN*735 <br />.0 <br />(2) <br />z_ <br />w <br />❑ UNKNOWN <br />i <br />DATE DISCOVERED -^�'/I <br />HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />�v <br />❑ TANKTEST ❑ TANK REMOVAL OTHER <br />a <br />m <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />> <br />UNKNOWN <br />❑ REMOVE CONTENTS ❑ CLOSE TANK 6 REMOVE ❑ REPAIR PIPING <br />w <br />M M 0 01 Yl Yl <br />❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED 7 <br />0 <br />❑ VES ❑ NO IF YES, DATE <br />❑REPLACE TANK ❑OTHER <br />M M o o Y <br />y <br />�¢ <br />SOURCE OF DISCHARGE �/ <br />E:] TANK LEAK UNKNOWN <br />CAUSE(S) <br />❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br />Om <br />O ❑ PIPING LEAK ❑ OTHER <br />❑ CORROSION UNKNOWN ❑ OTHER <br />ww <br />N <br />CHECK ONE ONLY <br />R <br />O <br />❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />w� <br />❑ NO ACTION TAKEN Lo PRELIM INARV SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />j <br />LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />m ❑ <br />O <br />`U`U�CC��„'I'I/ <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 8 DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <br />az <br />00 <br />IgE MA HN DETN51 <br />❑ CAP SITE (CD) ❑ EXCAVATE B TREAT (ET) ❑ PUMPS TREAT GROUNDWATER (GT) REPLACE SUPPLY IRS) <br />w� <br />w <br />< ❑ CONTAINMENT BARRIER (CB) NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />m <br />❑ VACUUM EXTRACT (VE) ❑ OTHER (OT) <br />z <br />W <br />No <br />i� ��✓ <br />O <br />(� <br />U <br />11 <br />