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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)!CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMER SERVICES FOR LOCALMENCY USE ONLY <br /> ❑YES -,/� REPORT BEEN FLED? [ZYES ❑ NO t:HERWCERfI AI, I:AM:A.MATEDGOVERNMENT.tiOLOYEE`�THATINAVE <br /> LL�� I`� .SIS.NiFORMATiON TO IACAL;CFFK:tALS Pl 11M1f 7Q SECTION?5te47 GF <br /> REPORT DATE CASES <br /> wl 1.1r Oy :. <.,,. ... <br /> NAME OF INDIVIDUAL FLING REPORT PHONE I SIGNATURE <br /> N (,too 6 —3 wo ,G <br /> REPFEYENrING ❑ OWNEROOPEAATOR ❑ REGIONALBW1ip J u NCY SE <br /> uu�Q�Q LOCAL AGENCY OTHER7e curc <br /> ADDRESS <br /> S <br /> NAME CONTACTPERSON PHONE <br /> Q ❑ UNKNOWN <br /> d ADDRESS <br /> P.e. 13M ?7 NC4 WrATE <br /> FACLITY NAME(F APPLICABLE) OPERATOR PHONE <br /> ..moa <br /> ADDRESS 95-� r. <br /> Gcoultry 21P <br /> CROSS STREET TYPE OF AREA ❑COMMERCIALCgINDUSTRIAL❑RURAL TYPE OF BUSINEW C:] RETAIL FUEL STATION <br /> C:)RESIDENTIALE3OTHER E] FARM OTHER <br /> Q LOCALAGENCY �f AGENCY NAME OONTACTPERSON PHONE <br /> W rN t Edi 4rA Morl) Ma 391%' <br /> REGIONAL RO f PHONE <br /> � (t) NAME QUANTITY LOST <br /> c'PT oN UNKNOWN <br /> 11 <br /> � rT� j�r�'N�-- �NUNICNowN <br /> i DATE DISCOVERED r7 <br /> HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING F7NUISANCE CONDITIONS <br /> YL lo, o ?yl Oyl ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> W <br /> Y M DI 01 Y Y ❑ REMOVE CONTENTS ❑ REPLACE TANK U "LOSE TANK <br /> HAS BEEN STOPPED? El REPAIR TANK ❑ REPAIR PPING ❑ CHANGE PROCEDURE <br /> YES ❑ NO F YES.DATE /Y� Z� Z d 0 oI 7 v r ❑ OTHER <br /> SOURCE OF DISCHARGE TANKS ONLYJCAPACITY MATERNAL CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN0 GAL. [3 FIBERGLASS 77 OVERFILL 71REfAILURE <br /> t ❑ PIPING LEAK AGE V Jc AJ YRS YJ STEEL ❑ CORROSION [ZI UNIONOM <br /> D OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> CHECK ONE ONLY <br /> ❑ UNDETERMINED ❑ SOL ONLY ❑ GROUNDWATER ❑ DRINKING WATER. (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑} SIGNED OFF PSANUP COMPLETED OR UNNECESSARY) n <br /> ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVALABLE TO PROCEED ❑ EVALUATING CLEANLP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) `- <br /> ❑ CAP SITE(CO) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 810 DEGRADATION(IT)Ul <br /> / <br /> ❑ CONTAINMENT BARRIER(C8) ❑ EXCAVATE i TREAT(ET) ❑ PUMP 6 TREAT GROUNDWATER(GT) ❑ RNEPUICE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKLIP(HU) ❑ NO ACTION REQUIRED PAN ❑ OTHER(01) <br /> F /v�-k /7th1�.jtx� $Pr% esu N� /^Pt/F?N'� 5'0./ Q1+�. /...� /d•� r,! p,-� S'.��C ,.' I <br /> W G�- >�-t' �vr// 6�- /^�u/� -?`o c,L?7�Pj'yrtNP -{�ie� N�fte o.�.t� �r',�•y`' �' <br /> AQP <br /> r/ Necoslwal <br /> t <br />