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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICERFOR I.00kAGENGYLp ONLY: <br /> REPORT BEEN FILED 7 T HERESY GERTfF)f THAT E HE:A: TEA GQYER[�MEf�E E bIPtl3ttt AND THAT E NAVE;. <br /> ❑YES ❑ NO ._ ❑YES [] NO FiI.BQIiTEMATION:TfJ AL'#FICEN SRURSUANT TO S>CTION 2538Q7 OF <br /> REPORT DATE CASE r THS#EALTN <br /> NAME OF INDIVIDUAL FILING REPORT PHONE v81GNA <br /> REPRESENT ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> ❑ �,9.vr/� Ca Misr <br /> AGENCY OTHER <br /> 1 <br /> ¢ ADDRESS <br /> Cm STATE IP <br /> NAMECONTACTPERSON PHONE <br /> 9 r <br /> e ❑UNKNOWN \ } <br /> i ADDRESS <br /> W <br /> . �e �r STATE <br /> FACILITY NAME(IF APPLICABLE) OPERATORP HONE <br /> ADDRESS <br /> STAEFr COUNTY <br /> CROSS STREET TYPE OF AREAMMERCIAL❑WDUSTRIAL[n RURAL' PEOF13USINESS RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER ❑ FARM THER <br /> LOCAL AGENCYAGENCY NAME CONTACT PERSON PHONE <br /> u�rl <br /> REGIONAL BOARD PHONE <br /> i � } <br /> (1) NAME QUANTITY COST(GALLONS) <br /> S r / <br /> G�JWNOWN <br /> ❑ UNKNOWN <br /> DATEDISCOVERED Yf�' HOWDLSCOYERED ❑ INVENTORYCONTROL ❑ SUBSURFACE MONITORING E] NUISANCE CONDITIONS <br /> it v u �x o �o v r E:] TANK TEST ANK REMOVAL Q OTHER <br /> DATE DISCHARGE BEGAN. "UN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY)WN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> HAS 01 GE BEEN STOPPED? ,. ❑ REPAIR TANK REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p YES.❑ 'NO IFYES.DATE- u M o D r v ❑ OTHER <br /> SOURCE OF.DISCHARGE: TANKS ONLYZAPACITY MATERIAL CAUSE(S) <br /> El TANK LEAK.. UNKNOWN :3OIO GAL. ❑ F�IBE ASS O OVERFILL ❑ RUPTUREIFALURE <br /> PiPL410LEAK AGE YRS STEEL ❑ CORROSIONUNKNOWN <br /> ❑ OTHER : NKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> m CHECK ONE ONLY <br /> ❑ UNDETERMINED'- SOIL ONLY Q GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> Y! CHECK ONE ONLY <br /> ❑ SITE-INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ❑ WQ CTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APP,EiOPRIATE ACTIONS)(SEE SACK FOR DETAILS) <br /> ❑ OIW,.SITE(CD) ❑ EXCAVATE 8 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(I7) <br /> 2 ❑ CONTAINMENT BARRIER(CS) ❑ EXCAVATE 6 TREAT(ET) ❑ PU TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HtQ ❑ <br /> NO ACTION REOUIRED(NI) Ea OTHER(OT) <br /> %g,✓,E �md✓9� �.;L. /?esv/�S /2r�� G'vr�f��tia�lic�, r'�i'2,�`�n si : <br /> U Ksc 06(4#871 <br />