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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT } <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES :::.FOR:LOC. AGENCY;USE ONLY <br /> REPORT BEEN FILED? #.:}IEREB :G TkU[T E AM A pESICaN1lTEQ GQVERNFAE ET EIYIPLlJY E h V:THAT<E HAVE <br /> ❑ YES NO YES [] NO `AE iS.i FURMAT((N1...TlZ IOCAk C1FFlCfAIS.P(1fiSl7ANt TQ..S GT[QN.25t8Q.7 OF <br /> REPORT DATE CASES THE" a <br /> U Y YSIGNED <br /> flA E. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATUR <br /> m <br /> a REPRESENTING 0 OWNE WOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> LOCAL AGENCY ❑ OTHER <br /> Lu <br /> a <br /> ADDRESS <br /> a. I cLoS ��lJ t� 4G GS?-Q�, <br /> STREET CRY STATE ZIP <br /> NAME c CONTACTPERSON /PHONE <br /> Lo L. ❑ UNKNOWN . l (91 to) 43-11 <br /> R d ADDRESS " I <br /> it �LL�`bl`' t9Vt� 1ti C] �t,1 i2P1rr�, UfY-Ni <br /> STREET CRY STATE ZSP <br /> FACILITY NAME(IF APPLICABLE) N OPERATOR PHONE <br /> o IL 1 1 <br /> y <br /> ADDRESS ! J m <br /> c03 144 tA• CZ. k5vw Ir+ x°520 I <br /> STREET GRY COUNTY ZIP <br /> y CROSS STREET TYPE OF AREA 4j COMMERCIAL❑ INDUSTRIAL❑RURAL T SPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> C� li3�� ��j ' ❑ <br /> RESIDENTIAL =OTHER ❑ FARM OTHER <br /> i <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> P cj. .(�o, Pis UIQ . �1 (7c�rsi �� t`ll ? MAI <br /> u REGIONAL BOARD ' PHONE <br /> 9 1j Pat VIV L.Wlwvr-( , C. i3; &ANb5 'TIk" fq pfd t -612-(,-- <br /> NAME <br /> 512NAME QUANTITY LOST(GALLONS] <br /> y <br /> UNKNOWN <br /> Z { <br /> ai ❑ UNKNOWN 1 <br /> F DATE DISCOVERED NOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS {� <br /> 0m M ✓f� D `�= o ! r r 0 TANK TEST ❑ TANK REMOVAL Lj OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M D D Y Y UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANKLu , <br /> n HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> % YES ❑ NO IF YES.DATE M M DI Y ❑ OTHER <br /> Lu SOURCE OF DISCHARGE TANKS ONLYCAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK •UNKNOWN GAL. ::❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE j <br /> v ❑ PIPING LEAK AGE YRS ❑ STEEL ❑ CORROSION % UNKNOWN <br /> ❑ OTHER II UNKNOWN OTHER ❑ SPILL 0 OTHER <br /> w W CHECK ONE ONLY <br /> CL <br /> ❑ UNDETERMINED ❑ SOIL ONLY R GROUNDWATER ❑{ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ON'-:ONLY <br /> 2 N <br /> rr ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ] .CLEANUP IN PROGRESS 0 SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> V m ❑ NO ACTION TAKEN POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ;,❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) _ <br /> z ❑ CAP SITE(CD) } ❑ EXCAVATE&DISPOSE(ED) {❑q REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) :' 176 I PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑L TREATMENT ATHOOKUP.,(HU) ❑ NO ACTION REQUIRED(NA) `t❑� OTHER(01) <br /> S},k< CiS1�1�M ttl 1 <br /> LLI <br /> �• S Nei t yYls'i�; 1�k,Is flC� Qq C. of 1. ,Itii� Irks amu-{ <br /> i MSC oe(467ry <br />