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' UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT <br /> ERGENCY <br /> '-+ r 11A.S I TATE OFFICE OF EMERGENCY SE7, w <br /> tt�+l�AGENt OWY `+ •• f'' < � - i' t�rr,�^ �•,eSi�{rf.,`� <br /> '�' t REPORT Bl;EN FI,F.D 1 FiE8Y�ER71FY I SKIt{ATED(�bVFANl+�3(!'iC��N4 Mr��'� <br /> YES ❑ NO 'EORTED INF LocX CFFM.$ F'U MA h7 YO!£GT1C1N 25sa?DF <br /> HEAT r ;> t <br /> REPORT DATE CASE <br /> o,A s. o y g" Y ' <br /> NAME OF INDIVIDUAL FILM REPORT F"ONE s+cwATURE <br /> �d i/Kr1S <br /> COMPANY OR AGENCY NAME 1 <br />' REP RESENTWG ❑ OWFERIIPERATOR ❑ R6GIDh1ALBOARD M. LION a.;+�. LBG�-} P+��'fi�" D�S ✓�C <br /> n <br /> LocAL AOE1iCY , <br /> STATlE' <br /> NAME <br /> CONTACTPERSON <br /> aADDREss C 1�4 z-.0 `f <br />' Zas n� STATE <br /> 3 ' <br /> FACLITY NAME(IF APPLIGABL.Q / �C�roR 1 v <br /> rVICAP— `7 vIt C.1 eM 4•�"r� \' I*`�T�� ~��Z,.V <br /> ADDRESS <br /> z� IS N �� 110 a <br /> yGROSS STREET TTYPE OF AREA ❑COMMERCIAL ❑ NOUSTRIAL❑RURAL TYPE OF BUSINESS RETAUL FUEL STATON <br /> ESDEN E ❑OTHER C❑ FARM CD OTHER. <br /> LOCAL AGENCY AGENCY NAVE CONTACT PERSON PHONE <br /> Zo-T Ldbit-3 y! 9' <br /> w S a „i PHONE <br /> REG/�"AL BOARD <br /> t�C�`�•r. c��f (9 l i, f°(—s-r- 0 4 <br /> NAME pUA1TFTY LOST(GALLONS) <br /> (11 <br /> UhlCN0Wd <br /> ' r DATE DIsr-ovERED .HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE rICNITORNG ❑ NUISANCE COND=04S <br /> Z <br /> a- TAN(TEST TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN AAETHOO USED TO STOP 019C�(CHECK ALL THAT APPLY)( <br /> ' UNKNOWN ❑ REMOVE CONTENTS a REPS-ACE TANK CLOSE TANK <br /> ul 01 pi <br /> l fl <br /> RE <br /> M A Y —Jl I HAS DISCHARGE 8EEN STOPPED 7 REPAIRTANK REPAIR PPNG CHANGE PRQCEDUvEg ❑ r.Y) IFYES CATS Oul DI OTHER Lf � In � t 0SOURCE OF DISCHARGE TANKS .N+LY-AYACITY MATERIAL CwS`(s) <br /> i ❑ TANK LE+4C UMCN05AM 4e - ---� ❑ FIBERGLASSOVERFLL -yRLJPTUFiE�FALUR <br /> 2 ❑ PIPING LEAK nL <br /> YRS STEEL ❑ CORROSION A� I UNKNOWN <br /> ' ❑ OTHER UNKNOVM 777`❑�� OTHER ❑ SPILL ❑ OTHER <br /> W CHECK ONE ONLY <br /> ❑ UNDETERIAWED SOIL ONLY ❑ GROUNDWATER ❑ DRINK NG WATER (CHECKONLY FWATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHEOK ONE ONLY <br /> vl ❑ <br /> SITE NVESTIGATION IN PRC�RESS{DEFINING EXTENT OF PROBLEM) ❑ GLEANLP[N PROGRESS ❑ SIGNEOOFF LCLEAFJUP COMPLETED OR UNNECESSA <br /> cr in ❑ NO ACTION TAKEN ❑ POST CFJINJP 61ONITORNG IN PFgGRESS ❑ NO FUNDS AVAtABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> u <br /> CHECK APPROPRIATE AC71ON{51(SEE BACK FOR DETASLS) REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> Y ❑ CAP SITE LCD) ❑ EXCAVATE a DISPOSE(ED) a <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE a TREAT(ET) <br /> ❑ PUMP III TREAT GROUNDWATER tGT1 ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATUENT AT HOOKUP(FU) ❑ NO ACTION REQUIRED(NAT ❑ OTHER(OT) <br /> �' ��� \ t.o�I A -� ���oA-. ,.ti.a�t� dv✓�Ih(, �C,-�� ✓'t-w�-7vc.� � Coll <br /> U,J j'f-jr". S C) 1 s V <br /> n sc os lu" <br /> �``T r - <br />