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(ski ,,no,n ilc*ur <br /> UNDERGROUND.STORAGE,,-TANK,UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY ;,ill 'NAS STATE OFFICE OFEMERGENCY SERVICES TOgCtlCdL�1NCYUS :O,Nfit,?.. <br /> I' REPORT BEEN FILED r Hfcf�E� C I IFY:7HAT f hM A C 91c Q QVf NM NI �MRL0Y E ANb. 4At t Fadi <br /> 0 <br /> YES No [ YEA Q No p�pp pt I$IN�QRMATfON T�1 L0� i7FFlGIlIL3 E.. RStiA'1:1'O SECTION 251807_'F; <br /> REPORT DATE CASE THE HEAL ANO:SAFiY t% E <br /> ::<:;:; <br /> 1 ev? M 2 S' a v Y v SIf3NED...;»r:..:;;:<.;< ::.;::.:...:: <br /> DATE;: <br />{ NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> i <br /> REPRESENTING O OWNER/OPERATOR Q.'REGIONAL BOARD COMPANY OR AGENCY NAME u <br /> LOCAL AGENCY OTHER o. .�0 4 iL• <br />! ¢ ADDRESS _ <br /> gzi4 2- <br />{ <br /> STREET' CITY STATE ZIP <br /> NAME CONTACTPERSON PHONE , <br /> /• <br /> Ej UNKNOWN �1f �J V tr A, ( ) <br /> y a ADDRESS <br /> rd(. 1 v lot L. c L ` <br /> ¢ cyy <br /> STREEt Ctl'VJ -STATS P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> Ca„�,; �� <br /> �a. �"�J �1lah..-�•.c�..,/�... �c. 1� ,I ,. (204) S Sr.-L260 <br /> ADDRESS q• , <br /> ZIP <br /> y CROSS STREET s ` ` s TYPE OF AREA COMMERCIAL INDUSTRIAL pURAI TYPE OF BUSINESS M RETAIL FUEL STATION <br /> RESIDENTIAL 0 OTHER FARM'D OTHER; <br /> LOCAL AGENCY ~r AGENCY NAME (� 1 CONTACT PERSON s a PHONE <br /> W c... Soq` �.*' Lo#-.I I �e�H►� ,J i S'T Le,w. i� LO'4..1�g (Zd4) �I(o�"3 y 2 8` <br /> REGIONAL BOARD PHONE <br /> C�_l VCJkle <br /> (i) NAME OUANTRYLOST(GALLONS) <br /> Y oIQV w� �y o C"LjERUNKNOWN <br /> (2) <br /> g-e-,zL-p� 15ZUNKNOWN <br /> DATE DISCOVERED r. ., HOW DISCOVERED 0 INVENTORY CONTROL O SUBSURFACE MONITORING a NUISANCE CONDITIONS <br /> M b M o So_ �v `f J 0 TANK TEST TANK REMOVAL Q OIFIEf�'I <br /> DATE DISCHARC3EiBEGAN t, p+ _ I r I>J Y {i tn4OD USED TO STOP DISCHARde(CHECK ALL THAT APPLY) <br /> M M tl op' v v IUNkNOWN i REMOVE CONTENTSt REPLACE TANK CLOSE TANK <br /> 8S HAS DISCHARGE BEEN �OPPED T ; 1 - REPAIRtlUlk) U O REPAIR PIPING : CHANGE PROCEDURE <br /> p. YES Ej NO IF YES DATEM O ( p" D �� rP Y .OTHER ! <br /> SOURCE OF DISCHARGE,, 1 TANKS ONLYICAPACITY MATERIAL CAUSE(S) <br /> F--] TANK LEAf� ' I Z I UNKNOWN ��� 64 .I Q FIBERGLASS O UVERFILL RUPTURE/FAILURE <br /> El PIPING LEAK .' AGE YRR 0 STEEL F__j CORROSION UNKNOWN <br /> E] OTHER ` UNKNOWN c Q OTHER SPILL a OTHER <br /> CHECK ONE ONLY •, <br /> Q UNDETERMINED y SOIL ONLY E:]I GROUNDWATER DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F- CHECK ONE ONLY <br /> ¢ F-1 SITE IJVE§TIGk1bN IN PRbORESS(DEFINING EXTENT OF PR09LEMj O CLtANUP IN PROGRESSQ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ¢F <br /> rn NO ACTION TAKEN 1� POST CLEANUP MONITORING IN PROGRESS Ej NO FUNDS AVAILABLE TO PROCEED Ej EVALUATING CLEANUP ALTERNATIVES <br /> I CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> f CAP SITE(CDj- .` Q EX(:AVATE&DISP�SE(ED) �' REMOVE FREE PRODUCT(FP)• ENHANCED BIODEGRADATION(IT) <br /> c� a CONTAINMENT(1ARRIER( ) EXEAVATE 8 tREA (ET) PUMP 3 TREAT GROUNDWATER(GT) Q REPLACE SUPPLY(RS) <br /> TREATMENT At HOOKUP(NU) NO DICTION REQUIRED(NA) Y 1� OTHER(OT) <br />�. �„-t-a,,,..'(V,...\ •�G L'� �{ \-, , ,\. G_I,. %"A'L ••���% `t,. �( 0.1 k�::�...._ p T <br /> �. rc <br />• HSC O5(4AFn <br />