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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK) CONTAMINATIONSITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICE ,FQR LOCALAGENGY USS ONLY <br /> REPORT BEEN FILED? <br /> Q YES NO �]YES �HEREBY CERTIFY THAT!Ah1 A OESIGN74TImGOVERNMENT EMPL:OYR AND THAT,I HAWS <br /> F EPORTED:THl5 tNF MATION TO EOCAL OFF[CtALS Pf1AgUANT TR SECTK7IV 251807 OF <br /> REPORTOATE CASES THEH AND E <br /> u I M / D Y Y SIGN OATS <br /> NAME7 INDIVIDUAL FILING REPORT PHONE j SIGNATU <br /> {zaci) �� 3y� If <br /> REPRESENT OWNEWOPERATOR REGIONAL BOARD Col <br /> OR AGENCY NAME <br /> aLOCAL AGENCY OTHER <br /> ADDRESS <br /> Ale- <br /> ClTV STATE <br /> Zip <br /> u� NAME CoNTACTPERSON ;, PHONE <br /> Jf <br /> (� ❑ IRJKNOWN UN I✓ �v�j 1%�y-yr03 <br /> d ADDRESS <br /> LLI <br /> a0/ Missi�,ta - SOITE � ,y cv Cr- 'iS(10 <br /> STREETCITY11 P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR1pypNES <br /> a ADDRESS If <br /> 1515- r,J _ <br /> STREET r <br /> C f,! <br /> I <br /> CROSS STREET TYPE OF AREA [D COMMERCIAL INDUSTRIAL❑RURAL TYPEOFBUSINESS 0 RETAIL FUEL STATION <br /> Q RESIDENTIAL Q OTHER Ir I O FARM E�rDTHER <br /> LOCALAGENCY AGENCYNAME CONTACTPERSON PHONE <br /> ELu IONAL BOARD PHONE <br /> CL <br /> IIS <br /> wa (f) NAME QUANTITY LOST(GALLO <br /> d. UNKNOWN <br /> 0 (Z) <br /> Ii UNKNOWN <br /> DATE DISCOVE RED HOWDISCOVERED O INVENTORY CONTROL. SUBSURFACE MONITORING E:] NUISANCE CONDITIONS <br /> ' <br /> M IuD I �D v <br /> a TANK TEST TANK REMOVAL Q OTHER <br /> DATE DISCHARGE BEGAN ,/,�, METHO ED TO STOP.DISCHARGE(CHECK ALL THAT APPLY) <br /> M M a D v r u UNKNOWN REMOVE CONTENTS REPLACE TANK CLOSE TANK <br /> HASDISCj�ARGEBEENSTOPPED? �� REPAIR TANK ill � REPAIR PPM � CHANGE PROCEDURE <br /> d 1�//YES E] NO IF YES.DATE M I M D D g r 7 v E "�R an d f/4,e <br /> u� SOURCE OF DISCHARGE TANKS ONLY00APACITY MATERIAL CAUSES) <br /> 4 TANK LEAK UNKNOWN GAL- Q FIBERGLASS "« OVERFILL RUPTURE/FAILURE <br /> PIPING LEAK AGE YRS STEEL :} ❑ CORROSION K;j NKNOWN <br /> Lj OTHERUNKNOWN Q OTHER ii ; E:] SPILL Q OTHER <br /> W w CHECKONEONLY <br /> CL <br /> UNDETERMINED D SOIL ONLY GROUNDWATER Q DRINKING WATER-i(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED). <br /> CHECK ONE ONLYZ co <br /> ;a <br /> wc g ❑ SITS INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) 0 CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY). <br /> y NO ACTION TAKEN POST CLEANUP MONITORING IN PROGRESS ND FUNDS AVAILABLE TO PROCEE6 EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> oO ❑ CAP SITE(CD) EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> w CONTAINMENT BARRIER(CB) EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> Ej TREATMENT AT HOOKUP(HU) NO ACTION REQUIREO(NA) OTHER(OT) Y <br /> y r'tft�(. 5!�/ Qssfsssn�.rf lWlc_(- BC deC-e7 Xe 70 DET&-e/L-�/,�JA;F 7-H,.57 A)6ru,Sr .41VO <br /> E,C1 r ®F C� r�rro ry 3Y 77f—,-� g Pio Perms ACxfV <br /> ii <br /> HSC OS(4A7i <br />