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UNDERGROUND WORAGE TANKUNAUTHORIZED RELEASE(LEAK)/C01�ITAmuTION3'M REPOW, <br /> ❑ <br /> YES ❑� <br /> - •Y. :`�;:'?:�?: :iii .,Y„ <br /> REPORT DATE <br /> tw <br /> +O <br /> :.: v:•L::ivv:^vs .ii:i:::::::::::v::.�:.� :i:.., .:.:. -:.iY::.,...-:i-....r.:-..:..vY:�i. <br /> NAME FLM REPORT PHONERE <br /> � r <br /> �o <br /> (ANNE <br /> . _ MMONAL BOARD 1 G <br /> n ,y, , La• �' <br /> AGENCY ❑ OTHER. , Y. <br /> f � <br /> NAME CONTACTPERSON PHONE <br /> UNKNOWN c <br /> ADDRESS <br /> slim' <br /> FACILITY NAME(F APZF .. t oPERATC3p NHOIE <br /> Ce <br /> c <br /> ADDRESS <br /> CROEB atpEET TYiE of AREACOMMERCIAL Q C3R[JRAL. TYPE OF eU8M83i! ❑REFAIL FUEi STATION <br /> E:jm mnt U OTHER ❑FARY O� <br /> CONTACT PERSON - . <br /> FEGIOIW 9OARD PHONE <br /> Va Xbover VI >5W <br /> hI NAME OL1ANftTY LOST([LIIL LON ) 1 <br /> FIOWDMCJOVEFiEO ❑ MfYENTCIRYCONTpOL SUMMACE. 7NfraR/+o Q NUISANtE00FDTTIONS <br /> ❑J TANNt'k W ❑ TANK FaWAt ❑ blHgfl <br /> Dk,6D18G1AliL Ti F1Q01�/EQ!Oltt1PD E 0.4m TiYITAMM <br /> M16WWUTBM ❑ REPLACE TANK CLOSE TANK <br /> HAS OISCHARGE BEEN STOPPEDI ':: ❑ RE:PiuR TANI( ❑- REPAM PPM ❑ CHANOE PR008XM <br /> YES ❑. fYEStooc <br /> OFMAIMW <br /> ❑ TANK LEAK` L*XNOIMO .R F9 FIBERMAq ❑ ON>93FL1. ❑ RUPTUFiFJFALURE <br /> ❑ PPMbLEAK A E YR; ❑ CDRIK WON IR:UNKNOWN <br /> ❑ m}Ep C7 [3-WILL .❑ OTHER <br /> ONECKONEONLY <br /> ❑ UPD m%o—m•- CJ SOLONLii tEil ❑ ORNBCNIt WATER-(dE(9f ONIY yIUl>FRM�Jy9ilAVE ACTUALLY BEEN AFFECTEE» <br /> CHECK ONE ONLY <br /> SmWVE$TmlimNImoi E9s .EX1 wC0P*LwQ �L6AlIlPFMPA0 88❑ sKLFEgOFF(t>f.EANuPoOAAPLETEDoRUNNECEmm" <br /> NO ACT"MM *. ❑ .JIDbT OLEANuP w SSB ❑ W FUWl*AVAL*"TO PROCEW EVALUATWG CLEMKP ALTEFWTAIES <br /> CHECKAPP`AOPWTEAVrlO"4SEE9=lMOETAWI <br /> ❑ cAP BITE(= ❑ EILCAVATE F;F)sPoF)E(ED) p FIEMOVFS FREE PRODUCT <br /> eww=D BIO DEORADAT m(IT) <br /> ❑ CONTAMWff BARRIER(* ❑ EWAVATE A TFM�T(ET) ❑ PUMP&TREAT GROLMDMTER jn ❑ REPLACE SUPPLY(RIF) <br /> ❑ TREATMENT AT HOOKAP 0,M ❑ NO ACTION R90UE0 Q" <br /> OTHER(01) <br /> bea i n lRg� �,�riotea- 1�g° a� 12oauAdqrrcQ• <br />