SITE INFORMATION AND CORRESPONDENCE

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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES REPORT BEEN FILED 7 FOR LOCM AGENCY USE ONLY ❑ YES NO ❑ YES ❑ NO I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TOT DISTRIBUTION SHOWN ON THE TRUCT N SHEET ON THE BACK PAGE OF THIS ORM REPORT DATE /%j CASE a MI � [ YI Y SIGNED DATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE in 7 17 ow REPRESENTING F-1 OWNER/OPERATOR F-1GK)NAL BOARD COMPANY OR AGENCY NAME o LOCAL AGENCY ❑ OTHER 1/ �1 hN jomtvui I/� ADDRESS h Ro 2 y �'y GJT �/y D STREET V v ... /�! �A STATEZIP / w NAME _ CONTACT PERSON PHONE 5 ( �3S- y7 Z 1} A L Fg�t, ISI UNKNOWN �' Ua c ADDRESS N 757b Wi N " w STREET CIT' STATE p FACILITY NAME(IF APPLICABLE) t0& OPERATOR PHONE aL4 rlOAj ~ ADDRESS A JA. �V V�REE>I !/, 7 l•/ O/ CITY COUNTYf P CROSS STREET C C7 LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE w w U w w REGIONAL BOARD PHONE a. c V. a c c & /S6 ao y (1) y �^ �/NyAME QUANTITY LOST(GALLONS) W Z / I� t/� r.,% I 1 1 V �/O!v� ❑ UNKNOWN U w <J m O (Z) z y ❑ UNKNOWN w DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS w u1 d p) yl y ❑ TANK TEST TANK REMOVAL ❑ OTHER m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) M o Y ❑ UNKNOWN REMOVE CONTENTS ❑CLOSE TANKS REMOVE ❑REPAIR PIPING Lu HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE G U +� LI) ❑ YES ❑ NO IF YES.DATE II ❑REPLACE TANK ❑ OTHER O MI FW p YI Y �ul SOURCE OF DISCHARGE CAUSE(S) j ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL a U ❑ PIPING LEAK ❑ OTHER F7CORROSION UNKNOWN ❑ OTHER w w CHECK ONE ONLY v [_ UNDETERMINED ❑ SOIL ONLY Pg GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY w F7 NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION 2 N F7 LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS U ❑ REMEOIATK)N PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) (SEE SACK FOR DETMI <z 50 F7CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)E:] REPLACE SUPPLY(RS) w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) cr ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) �TG�Q � oiL GpN<�Mii✓�fO�J �'vM 2— "7'S .f��h�-/✓*"� W B'� //-/�iL-9 j • �7�'� s%f e a sSe SS rr W GL b� 4*e- of k U " d r JAJ r2 - " ro ftd;- w� SSC 05(8* � �y.