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�i_ <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY <br /> REPORT BEEN FLED 7 )HERM CERTIFY THAT{AMA DESIGNATED GOVERNMENT EMPLOYEE.AND THAT E HAVE <br /> YES dNO r�YES NO :REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25t8B.J OF <br /> REPORT DATE CASES --rr-- THEN 1N SAFTYCOD <br /> MI V-MI D V O Y O Y <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGPI TURE <br /> (2c?)co 6 b <br /> w REPRES ING ❑ OWNER/OPERATOR ❑j REGIONAL BOARD COMPANY OR AGENCY NAME <br /> LO <br /> ❑ OTHER S?n! l/ (/I1� CQuA C"'v(rot'�P4I QCIN� <br /> R <br /> s IADDRESS ��(( <br /> 60/ 57 1klff*oPJ STREET - CITV STATE .�V ZIP <br /> NAME CONTACT PERSON PHONE <br /> co <br /> � ) <br /> z O� C L+ ❑ UNKNOWN <br /> aADDRESS QI'le0o <br /> cn <br /> 2 6 S n�'1 INvSTREEf cN1 C( CRY N� STATE / ZIP <br /> FACILITY NAME IF APPLICABLE) OPERATOR PHONE <br /> Nio� ac, /r )124' Aittr <br /> ADDRESS <br /> cm �n/ V UIN courm P <br /> CROSS STREET TYPE OF AREA a COMMERCIAL INDUSTRIAL RU RAL <br /> TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER a FARM ❑ OTHER <br /> p LOCAL AGENCY AGENCY NAME E �� CONTACT PERSON PHONE <br /> Z A.vlrvrh��,�, <br /> W <br /> w LLJ PHONE REGIONAL BOARD � ) <br /> IL <br /> (T) NAME QUANTITY LOST(GALL NS) <br /> N <br /> U p UNKNOWN <br /> UJ <br /> (2) <br /> ❑ UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED ❑ VENTORY CONTROL ❑ SUBSURFACE MONITORING F7NUISANCE CONDITIONS <br /> z <br /> w ^ ^) ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> GM M /',D ♦ D Y Y <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> 2UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK �IOSE TANK <br /> N M M D D Y v ❑ul <br /> HAS DISCHARGE BEEN STOPPED 7 REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p [VYES ❑ NO IFYES,DATE al MI ODI SDI '7,1 ov ❑ OTHER <br /> u� SOURCE OF DISCHARGE TAN..KSS ONLYr-APACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN S. W_6 _GAT- BERGLASS ❑ OVERFILL �LIPTURE/FAILURE <br /> 2 F7 PIPING LEAK AGES YRS STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER IVUNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w w I CHECK ONE ONLY <br /> U ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F I CHECK ON'ONLY <br /> SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cc <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINNG EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS F7 <br /> U w I ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVA0.ABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> 2 ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) ` <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTbN REWIRED(NA) ❑ OTHER(OT) <br /> Cdi// �- �u�1'P�I fe ��-fPrwri.�e � �/rir� a.�/ Pxfr,..f of r'oM�r,,.,�,✓efi�..� as � <br /> ce 9 <br /> HSCOS(MM <br />