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FREPORTOATE <br /> ERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY:USE ONLY - ! <br /> REPORT BEEN RILED? ❑YES ❑ NO 4 NERE gPORgE THIS tNFORMATIONA DESIGNATED IC PURSUANT TO SECTION 2sie, OF <br /> NOI.CASExTHE 7H SDE SIGNED WTE <br /> o YJ Y r ,: <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br />�. ✓ems( tia W�,3 Aa Gst <br /> L� AAM <br /> w REPRESENTING —1pWNERK)PERATOR - 1REGI LBOARD COMPANY OR AGENCY NAME <br /> I` ¢ LOCAL AGENCY ❑ OTHER <br /> 1 <br /> ADDRESS /� /� /y S-70 <br /> % � V�/{/.��1{ S� I <br /> t 0• V SRIEET V J /04 / U'!V SLATE ZIP <br /> j NAME <br /> CONTACTPERSON PHONE <br /> J11 7 <br /> 1 a WL E <br /> ADDRESS IQdOWN ( �J9 37 <br /> I <br /> __ � Y � r/J�STiiEEI✓ ' �/� � /J"V Crtv / STATE � /�'ap <br /> FACILITY NAME(IF APPUCABLE) v OPERATOR PHONE <br /> ADDRESS. <br />�. TiiEEf / /�-/✓� CITY qr' 7 .YJ <br /> PE OF BUSINESS RETAILFUEL STATION <br /> y CROSS STREET ,/p EOF COMMERCIAL❑INDUSTRIAL❑RURAL ❑ <br /> /?OL L ��/L� V e- ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCAL/AGENCY AGENCY NAME CONTACTPERSON PHONE <br /> u REGIONAL BOARD PHONE <br /> � 6 <br /> ( NAME OUANTTTY LOST(GALLONS) <br /> w <br /> roG�R-��� ❑ UNKNOWN <br /> J <br /> I �O (2) <br /> ❑ UNKNOWN <br /> DATE DISCOVERED / HOWOISCOVERED F-] INVENTORYCONTROL E:] SUBSURFACEMONITORPIG ❑ NUISANCECONDITIONS <br /> w M M <br /> _3.1 <br /> 0 0 .1 <br /> !v / v ❑ TANK TEST TANK R O ❑ OTHER <br /> DATE DISCHARGE BEGAN ETH D TO STOP OISCHARGE(CHECK ALL THAT APPLY) <br /> c ❑ UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSETANK <br /> y M M O 0 V <br /> p HAS DISCHARGE BEEN STOPPED? ❑ REP/JR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p ❑ YES ❑ NO IFYES.DATE M M AI L,I YI V ❑ OTHER <br /> H SOURCE OF DISCHARGES TANKS ONLYiCAPACITY MATERIA. CAUSE(S) <br /> ❑ TANK LEAK /`♦. UNKNOWN O GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ gUPTUREFAILUPE <br /> 0 ❑ PIPINGLEAK T• - AGE YRS ❑ STEEL ❑ CORROSION ❑ UNKNOWN 1 <br /> �. ❑ OTHER Tx UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> W w CHECK ONE ONLY <br /> V� N UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKNQWATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> �� ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> V m ❑ ROGRESS ❑ NO FUNDS AVAILABLE PROCEED ❑ EVALUATINGCLEANUP ALTERNATIVES <br /> NOACTIONTAKEN ❑ POSTCLEANIPMONLTORINGIN P <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) ENHANCED BIODEGRADATION(17) <br /> 5 Z ❑ CAP SITE(CD) ❑ EXCAVATE 8 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(M ❑ <br /> `O"4 PUMP&TREAT GROUNDWATER(GI) REPLACE SUPPLY IRS) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(EI) ❑ ❑ <br /> ❑ Aj <br /> TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED INA) ❑ OTHER(OT) <br /> -90. %rlt�fti 2 side Q5s�55vNa^� r'v✓•'GL �se� <br /> O� Coi✓� ii✓ DN /�S ✓ cci2es� <br /> ( <br />