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UNDERGROUND STORAGE TANK UaUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> Noy HAS STATE OFFICE OF EMERGE Y SERVICES <br /> .FOR AL:40�NCY.: ONLY,: <br /> REPORT 13EEN FILED? 1.. <br /> 9 Y c Nd' �THE... <br /> 7Y E NO NO :;:.I HE:RE kVE,DIS4iD' ls'Zi ATI DIT:O.- ::;, <br /> SHOWN 04.THE INSTRUCTION SE ON THE BACK VAUt: <br /> REPORT DATE CASE III <br /> F'117 <br /> NAMEOF DIVIDU��LINGREPCRT PHONE SIGNATLIRE <br /> REPRESENTING <br /> IET-C *PERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> 0 ❑ LOCAL AGENCY ❑ OTHER <br /> a- <br /> ADDRESS 469 7, <br /> lrl,� - 12d. ctry 1 V STATE (;Or Zip <br /> w NAME CONTACTP ON <br /> PHONE <br /> co <br /> rn ❑— <br /> UNKNOWN A <br /> 0 <br /> 0-[L ADDRESS <br /> ui <br /> V) <br /> %tJX4194:�� CITY ST 0 <br /> FACILITY NAME(IF APPLICABLE) OPER P NE ZIP <br /> O <br /> < ADDRESS <br /> Lu o <br /> CITY <br /> O <br /> COUNTY ZIP <br /> CROSS STREET 7 <br /> (9 LOC AGENCY AGSCY NAME CONTACT PERSON <br /> z PHONE <br /> w 0 <br /> z (20) W-3440 <br /> W�w REC[IO-NAL BOARD <br /> 0 PHONE <br /> a.< <br /> NAME <br /> U QU LOST(GALLONS) <br /> > Ty <br /> [:] UNKNOWN <br /> w <br /> ti <br /> z <br /> 0 <br /> > (2) <br /> mz <br /> ❑ UNKNOWN <br /> DATE DISCOVERED DISCOVERED 0 INVENTORY CONTROL ❑ SUBSURFACE M NIT( RING ❑ NUISANCE CONDITIONS <br /> w <br /> m TANK TEST ❑ TANK REMOVAL <br /> z J-1 0-1 -?—.r (D�l ol'i OTHER :ml Lyf <br /> DATE DISCHARGE BEGAN <br /> w METHOD USED TO STOP DISCHARGE(CHECK ALL THAT�APPL <br /> cc UNKNOWN Ej REMOVE CONTENTS 0 CLOSE TANK REMOVE ❑REPAIR PIPING <br /> L>U- a, cly, 2-Y, E:i <br /> > HAS DISCHARGE BEEN STOPPED? CLOSE TANK&FILL IN PLACE ❑CHAN <br /> 8 F REPAIR TANK E:l GE PROCEDURE <br /> 7,1 <br /> YES 0 NO IF YES,DATE 1.16.1 REPLACE TANK OTHER <br /> w SOURCE OF DISCHARGE CAUSE(S) <br /> D <br /> cc:) F--j TANK LEAK KNOWN Fl OVERFILL ❑ RUPTURE/FAILURE< F-1 SPILL <br /> 0 0 <br /> V) ❑ PIPING LEAK OTHER CORROSION ❑ UNKNOWN g3--eTHER <br /> ui wn_l CHECK ONE ONLY lz5�� i t <br /> OArL4 � 't <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER E] O�IJKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Z ch <br /> w F NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> cr <br /> Er LEAK BEING CONFIRMED F--j PRELIMINARY SITE ASSESSMENT UNDERWAY <br /> M POST CLEANUP MONITORING IN PROGRESS <br /> 0 F--] REMEDIATION PLAN R��CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> ISM&�CK FCR WTAKS) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) 0ENHANCED BIC)DEGRADATION(IT) <br /> Z <br /> F3 o F--] CAP SITE(CD) ❑ EXCAVATE TREAT(ET) ❑ PUMP TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Lu <br /> w< ❑ CONTAINMENT BARRIER(C3) ❑ NO ACTION REQUIRED(NA) F--] TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> F--j VACUUM EXTRACT(VE) THERIOT) A A <br /> elj�d I)I JQ AAA d J� <br /> t Era <br /> z <br /> 0 CT 2 6 1992 <br /> msc 05("o) <br /> PERMIT) <br />