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. ., .. .,. . _.. is <br /> I <br /> UNDERGROUND STORAGE TANKNAIITHORQD RELEASE(LEAK)1yCONTAMINATION SITE REPORT <br /> r ,a ty r Y{Ns 3k y <br /> REPORT DATE , 'r CASE A : . - r `hh 12 h„ k <br /> may.��• <br /> w- - <br /> NAME O_F MIDfVIDL4ILFR(Fl(;REF�q; � r � 3�a ter" � F t _4 <br /> �. <br /> REPRESENTING OWNEROPERIITORr � ONALBGARD COMPANY ORACiENC1'NAME W <br /> LOC'.ALApElCY ��OTHER ' ,���. '�T+ ;'V.►.� v,% <br /> ADDRESS , s c' .. 3� - A ., , . iMr r• a <br /> Zp <br /> NAME CONTACTPERSON * PHDNE <br /> UNKNOWN Olt V; X209)' a <br /> A <br /> a ADDRESS ' y <br /> u1 n t_ C I <br /> FACILITY NAME(F APPLICABLE) it' { QPEFiATO1R 1 /p►�pp /- <br /> 'f;S-T'1.1�LA �.4. .. :1zol <br /> Iq <br /> -�� �- s.`Dv�►s'14w. s. ,C.+%�ay- IC d IVAt t`' •'�' ` <br /> ' CROSS STREET TYPE OF AREA COMMERCLLL 0 IhlDUSTRIAL RURAL TYPE OF SUS NESS 4 RETAIL FUEL STATION + <br /> 4! <br /> Ir P gE8[IENTIAL Q OTl1ER 0 FARM Q OTHER <br /> LOCAL AQENCY •,>, '_y. [( AGEtrCY NAME {_ CONTACT PERSON i PHONE `' f <br /> .�A�1`.��► rr•i•, R..oL4F ��LCT''� �t�vi�l �_� �QV�4 ��I•ts {�Rr�Ei���v�f:7 � <br /> REEGIOtIALBOARD <br /> C eF'ti-✓4 PHONE <br /> tq t6)3(6[-S'40o <br /> {�) NAME OUANTRY LOST(GALLONS) <br /> p <br /> �r v:�,4twk UNKNOWN <br /> fA <br /> i tt u <br /> Llmlox WN <br /> DATEDISCOVERED �+ HOW_DISCOVERED ❑ INVENTORYCONTROL SUBSURFACEMONITORINQ, NUISANCECONCffIONS y <br /> 0.1 1/ mi 34 p v'g y �' TANK TEST TAW REMOVAL ar► R 50i bo rinq <br /> DATE DISCHARGE BEGAN ' METHOD <br /> USED TO STOP DLSOHARGE <br /> (d#CIK ALL THIATAPPL , <br /> .UNKNOWN ^i�REMOVE CONTENTS F] REPLACE1TAW: CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? AJ REPAIR TANK E] REPAIR PIPING- F CHANGE PROCEDURE <br /> YES ❑ NO IF YES,DATE u rw o v v E] OTHER j <br /> SOURCE OF DISCHARGE TANKS ONLY+CAPACUY MATERIAL CAUSE(S) <br /> TANK LEAK ' UNKNOWN Ond GAL. FIBERGLASS D OVERFILL 0 RUPTUREiFALURE <br /> PIPING LEAK AGE YRS STEEL J O CORRKGION D?f UNKNOWN <br /> OTHER UNKNOWN i. OTHER v H�C . SPILL 0 OTHER 1 <br /> CHECK ONE ONLYww <br /> UNDETERMINED SOIL ONLY 0 GROUNDWATER DRINKt'JG WATER - (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK KNkE ONLY <br /> z s <br /> i Q SITE W VESTK3ATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) 0 CLEANUP N PROGRESS E] SK3NEDOFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> NO ACTK)N TAKEN 0 POST CLEANUP MONITORING IN PROD REBS O NO FUNDS AVAKMLE TO PROCEED ED EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> El CAP SITE(CO► EXCAVATE t DISPOSE(ED) 0 REMOVE FREE PRODUCT(FP)_ ENHANCED BK)OEGRADATION(IT) <br /> O CONTAINMENT BARRIER(CB) 0 EXCAVATE i TREAT(ET) 0 RUMP a TREAT GROUNDIIYATER'(GT) a REPLACE SUPPLY(RS) <br /> O TREATMENT AT HOOKI.IP m NO ACTION REQUIRED(NA) z _OTHER(o,)-_--- <br /> �\^ tt ! 44 <br /> 11 <br /> Lq.� �,ro <br /> I �jp``�e�.,.��vc.� Fp h 1r Gv ti l.s��i- ✓.w.�A w e, r 0-55 <br /> .Pe cl u r� r �"rva L r:ver f-r'Cod or-i zoM '� :EIC ►'►t "p' <br /> �� _ • l Q e01 c I .. `� _ x ;,� i -.>. - „ /M006(�R'7! _ <br /> '�` •-;az� tAa _ �r, r .. —T. 01V <br /> ✓ v <br /> :� <br />