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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERG SERV S FOR LOCALAGENCY.,USE ONLY <br /> ❑ YES djp REPORT BEEN FLED? 1/ YE3 NO pHEFEBY CERTIF'I:THAT)-AAI.A-0ES(GNATE0 GOVERNMENx EMPLOYEE AMD THAT I:HAVE <br /> REPORTED THIS tNFORMATION TO LOCAL OFFICIALS F{IRSUM T.TQ SECTION 2518QS OF <br /> REPORT DATE CASES THE HEALTH ANDS M <br /> �d Fy-j FY SMEfY <br /> re. .=: <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGNATURE <br /> co <br /> a REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> p �OCAL AGENCY ❑ OTHER �jyf <br /> 4 <br /> Lu ADDRESS �! <br /> STREET Cf7Y STATE ZIP <br /> NAME CONTACT PERSON PHONE <br /> C '7 2%f �I'ujrl % ❑ uNKNowNc�r_ / ' {; <br /> it <br /> !N7-e , , <br /> ADDRESS <br /> CL r �� <br /> !Q. �" /LJ. �rO cr. %t f;t'.''0,-;f ��7�GT�- ✓'� �_/r �.1vI C+tea <br /> srREEr /" em STATE av <br /> FACILITY NAME(IF APPLICABLE) V OPERATOR PHONE <br /> t ADDRESS <br /> ! lidC- <br /> W E CRY COUNTY 23P <br /> CROSS STREET /� �J TYPE OF AREA COMMERCIAL ❑INDUSTRIAL❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> z' Q��� I a(.' / 1�� ❑RESIDENTIAL ❑OTHER ❑ FARM ❑OTHER <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> Up <br /> u REGIONAL BOARD PHONE <br /> (I) NAME QUANTITY LOST(GALLONS) <br /> rC? ❑ UNKNOWN <br /> ❑ UNKNOWN <br /> OAfT£Dl�VERED �I ,.' HOWOISCOVEREDNK ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING <br /> ❑ NUISANCE CONDITIONS <br /> w / . u (//rD ✓D Y 4�f Y ❑ TATEST ❑ TANK REMOVAL [�OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> KNOWN REMOVE CONTENTS ❑ REPLACE TANKOSE TANK <br /> CC W N N O D Y <br /> 77YES <br /> AGE BEEN STOPPED T ❑ REPAIR TANK REPAIR PPNG CHANGE PflOCEDURE <br /> ❑ NO FYES,DATE .1 j of DI rI r ❑ OTHER <br /> SOUR DISCHARGE TANKS ONLY/y0AP/A�CITY MATERIAL CAUSES) <br /> 4 T NKLEAK �NKNOWN / - GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREFALURE <br /> t ❑ PIPINGLEAK AGE O YRS ©STEEL ❑ CORROSION �CNOWN <br /> ❑ OTHER E]-UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> wa ECK <br /> CHON NLY <br /> v UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKNGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z <br /> E SITE NVESTIOATKN!IN PROGRESS(DEFINNG EXTENT OF PROBLEM) ❑ CLEANUP N PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> H ❑ NO ACTION TAKEN ❑ POST CLEAM.EP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> a ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED Bio DEGRADATION(IT) <br /> M! ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE 6 TREAT(ET) ❑ PU b TREAT GROUNDWATER(GT) ❑ REM-ACE SUPPLY(RS) <br /> EN <br /> ❑ TREATMT ATHCOKUP(HU) ❑ NO ACTION REQUIRED INA) OTHER(OT) <br /> b 6rez tc i oS f s o n Sc r 1 �A0W 0-0.77 `a-Mf,a c��7eW, T��r h <br /> r <br />