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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I,CONTAMINATION SITE RE-PORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> O�LPqLArmmCY WE,ONLY <br /> YES Lj�NO REPORT BEEN FILED? NOy <br /> 1GNATFO�oov ..Em i�p .. :.N HK[ HAW <br /> �17: <br /> Aw'TO S <br /> YE� 7 <br /> REp.oR7 TKIS.AN"MATIONJO�LOCAVOFFC. SO W15010F. <br /> REPORT DATE CASE of 77 m. <br /> D] <br /> MI <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIG FUE:�,�-, <br /> REPRESENTING OWNEPJOPERA=TORREG:IO:NAL BOARD COMPANY OR AGENCY NAME <br /> LOCAL AGENCY ❑ OTHER <br /> w <br /> ADDRESS <br /> !�— .-+` r STREET 1�1 crry <br /> NAME CONTACTPERSON STATE PHOIE ZIP <br /> UNKNOWN IK-4 C <br /> "-4-lZF4- 151-;?79� )(- ;77 <br /> ADDRESS <br /> w 74 <br /> STREET <br /> crry STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> z Zt-pf-fL��- <br /> ADDRESS <br /> 4Z, I c67-rt kFM,4 A.1 Z A <br /> STREETCRVcou <br /> P <br /> CO3 CROSS STREET TYPE OF AREA M'COMMERCLAL INDUSTRIAL❑RURAL TYPE OF BUSINESS [k RETAIL FUEL STATION <br /> It It , 3 , ❑RESIDENTIAL E]OTHER ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> zqLu <br /> 2 Lu <br /> Lu REGIONAL BOARD <br /> PHONE <br /> W NAME QUANTITY LOST(GALLOt4S) <br /> FV UNKNOWN <br /> D- <br /> M [:] UNKNOWN <br /> DATE DISCOVE RED HOWDISCOVERED <br /> INVENTORY CONTROL E:] SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> -1/5 - -1. .z'yY El TANK TEST E:l TANK REMOVAL ❑ OTHER <br /> 1 1-61l 49 <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THATAPPILY) <br /> w MI MI DI DI YJ Y UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> f HAS DISCHARGE BEEN STOPPED 7 Ej REPAIR TAW ❑ <br /> REPAIR PIPING ❑ 3CHANGE PROCEDURE <br /> O C:] YES E] NO IFYES,DATE MI MI ol DI v� y [::] OTHER <br /> w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY I MATERIAL <br /> CAUSE(S) <br /> 0 TANK LEAK VUNKNOWN <br /> 9 . GAL. ❑ FIBERGLASS, F7] OVERFILL ❑ RUPTUREIFAILURE <br /> L) M PIPING LEAK AGE YRS E�KSTEEL ❑ <br /> CORROSIONvu NKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL [_] OTHER <br /> w Lu CHECK ONE ONLY <br /> UNDETERMINED LvSOIL ONLY 0 GROUNDWATER ❑ DRINKINGWATER.- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY III <br /> rn S <br /> ES SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> Lu 9 <br /> w SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN Pno <br /> n 0 NO ACTION TAKEN L:] POST CLEANUP MONITORING IN PROGRESS E <br /> NO FUNDS AVAILABLE TOPROCEEDEVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> z F-1 CAP SITE(CD) EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> 00 w- i� <br /> wm� F-�'CONTAINMENT BARRIER(CS) F-] EXCAVATE&TREAT(ET) PUMP a TREAT GROUNDWATER(GT) ❑ <br /> m REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) <br /> `7.AV.4/A/4 7jE� 2 1: <br /> .-e axa�.Celrnne-IAI <br /> w 4 IAIE a <br /> HS005(4ffn <br /> ---------- <br />