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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> 4 EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES :FOR LOCALAGENCY tISE ONLY <br /> ❑ YES REPORTBEEN FILEDT [:]YES ❑ 1 HEAES1f C�RTIFI THAT)AMA DESIGNRTEI]GGV�}iNMENf<EMPEOYE ANQTEikT i HAkI { <br /> NO <br /> FIEPDRTEIl Tk1iS (NFORN)ATION Tp LOCAL flFF(CIALS PURSUANT TO.SECTIQN 2S18d}pF< # <br /> REPORT DATE CASE THE HEAL ANO COIIE i <br /> �I a ml od )/a U Y 9r oAs : G <br /> NAME OF INcDIVIDUAL FILING REPORT <br /> D PHONE <br /> .I SIG N <br /> > 3'f <br /> m <br /> < <br /> COMPANY OR AGENCNAME <br /> Y <br /> o REPRESS NG ❑ OWNEFVOPERATOR ❑ REGIONAL BOARD <br /> Q LOCAL AGENCY ❑ OTHER <br /> O q,;,, �`o GL <br /> CL i <br /> a <br /> A f,ED, �1 x o20G� <br /> STREET ORY rl .f STATE 21P <br /> f�NA��ME� / ��, CONTACT P�E.,R/S�O_N/ it If f� PHONE <br /> a j <br /> z Q (2co 6z 1 dV�' ❑ UNKNOWN G,Q/C[ k�Cr� 6- a4 w <br /> 4 aa'Y!az ` Rew G I v� 3 <br /> ADDRESS <br /> Lu <br /> D STREET CRY SPATE IMP <br /> FACILITY NAME(IF APQPLICABLE) OPERATOR II RHONE <br /> ADDRESS <br /> w STREET ZIP <br /> y CROSS STREET TYPE OF AREA ❑COMMERCSAL INDUSTRIAL❑RURAL TYPE OF BUSINESS❑ RETAIL FUEL STATION <br /> {�� ❑RESIDENTIAL ❑OTHER I ❑ FARM 'OTHER <br /> LOCALAGEN AGENCY NAME CONTACTPERSON i I PHONE S <br /> W <br /> w REGIONAL ARD ? PHONE <br /> CL <br /> �2 CA <br /> y (I) NAME j' QUANTITY LOST(GALLONS <br /> LU <br /> �sl �ZC�C� I( UNKNOWN <br /> J <br /> rn <br /> r} ❑ UNKNOWN <br /> i <br /> DATE DISCOVERED C HOW DISCOVERED ❑ INVENTORY CONTROL UAFACE MONITOgENG ❑ NUISANCE CONDITIONS <br /> f �(} !i I <br /> w [:] TANK TEST ❑ TANK REMOVAL OTHER t <br /> L <br /> DATE DISCHARGE BEGAN (�(//, METHOD USED TO STOP DISCHARGE(CHECK ALL THA APPLY) <br /> M M o o r Y [ i UNKNOWN ❑ REMOVE CONTENTS 6 ❑ REPLACE TANK ❑ CLOSE TANK <br /> LLIp HAS DISC E BEEN STOPPED? ❑ REPAIR TANK I� ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p YES ❑ NO IF YES.DATE f M 0.1 oo a o �r � r � OTHER 'f <br /> u� SOURCE OF DISCHARGE TANKS ONLYACAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK ❑ UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL �TURE+FAILURE <br /> c ❑ PIPING LEAK AGE YRS E:]❑ STEEL ii CORROSION UNKNOWN <br /> �ER ❑ UNKNOWN ❑ OTHER it lly ❑ SPILL ❑ OTHER <br /> w CHECK ONE_ONLY �. <br /> v G UNDETERMINEDSOIL ONLY E::] GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED)Lu I <br /> � CHECK ON'ONLY i} �I <br /> wV1 } P E <br /> 2 a ❑ SI INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROG#ESS !E SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) lry <br /> v wNO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES � <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) ,' p <br /> a z0 ❑ CAP SITE(CO) ❑ EXCAVATE a DISPOSE(ED) ❑ REMOVE FREE PRC UCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE 5 TREAT(ET) ❑ P MP&TREAT GROUNDWATERR(GT)) REPLACE SUPPLY(RS) P <br /> { ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) OTHER(OT)cn , {� /i�yV ✓ <br /> D 26,-; <br /> sQ G117spec C-401 d� <br /> G c�.1 <br />