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<br /> A. SITE NAME B. CONTACT PERSON AT SITE
<br /> SITE ADDRESS
<br /> C.TELEPHONE NO.
<br /> - 2 3 o t�o �t-►� C� V lv�G � C.2oa� 3��- 4 5 � � '
<br /> CITY STATE ZIP CODE D. COUNTY E. COUNTY CODE
<br /> GA ct52110 SanJcaz(c Lr) 3c
<br /> F. SITE TYPE (CHECK MORE THAN ONE IF APPLICABLE,) G. Board of Egtrlimrion No.
<br /> ) —COMMERCIAL 71 RESIDENCE FARM OTHER—P""SPOCU)r. T Q H Y
<br /> H. DESCRIPTION OFTANK(S)USE
<br /> ❑ RESIDENTIAL MOTOR FUEL EIRESIDENTIAL HEATING OIL COMMERCIAL HEATING OIL ,'�n p
<br /> AGRICULTURAL MOTOR FUEL RETAIL SALE OTHER: �.G&wne—V-.1.j MotLu khl :.Q (�S2.
<br /> I. DATE RELEASE DISCOVERED J. DATE CORRECTIVE ACTION K. HAS CORRECTIVE ACTION BEEN COMPLETED?
<br /> WAS INITIATED:
<br /> 0 i f O �Q q•ILL -
<br /> LL -cl IYNO YES Date Completed:
<br /> L IDENTIFYTANK(S)INVOLVED IN CORRECTIVE ACTION(List Additional Tanks on a Separate Sheet)
<br /> CHECK IF CHECK IF
<br /> SWEEPS NO. LOCAL PERMIT NO. CAPACITY SUBSTANCE STORED TANK DATE REMOVED TANK
<br /> REMOVED 'r. Q�p� REPLACED
<br /> TANK 1 3 -13 2�-01 35 o gsol►rL e �] "j O o ❑
<br /> TANK 2 ❑
<br /> TANK 3 ❑ ❑
<br /> M. PROVIDE A BRIEF DESCRIPTION,IN CHRONOLOGIC ORDER,OF ALL ACTIVITIES RELATED TO THE UNAUTHORIZED RELEASE.FROM DISCOVERY OF
<br /> RELEASE TO PRESENT.
<br /> 4.21-85 Tc--"'4" �el�v✓ecl
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<br /> N. ATTACH A SITE MAP DRAWN TO SCALE WHICH INCLUDES A NORTH ARROW AND DISTANCES RELATIVE TO THE NEAREST PUBLIC ROADS.
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<br /> A. LOCAL UST PERMIT1lNG AGENCY B. LOCAL
<br /> NAGGFCY CODE
<br /> ,
<br /> • �,e.✓�,So a�c,v�n CoJ n �cn J I f'2')✓)Yt�l'}�-� (�2Cc'�,� �J
<br /> C. REGIONAL WATER QUALITY CONTROL BO D(RWOCB) D. REGION NO. E. L_AD AGENCY CASE NO.
<br /> F. LEAD AGENCY PROVIDING OVERSIGHT OF CLEANUP: LEAD AGENCY yC�ONTACT SON
<br /> o)[a RWOCS (2)4 LOCALAGENCY MU JOINT TELEPHONE NUMBER�
<br /> (Zcx( ) T 33- -
<br /> (REVISED I)N) (SEE FACING PAGE FOR INSTRUCTIONS) PAGE 3
<br />
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