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, - UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)1 CONTAMINATION SITE REPORT <br /> may ." <br /> HAS STATE OFFICE OF EMERGENCY SERVICE <br /> AOR tOCAr;AGENCY USE ONLY <br /> y REPORT BEEN FILED? <br /> _ [] <br /> YE JO ❑ YES No tHERE61'.CEFfT1FYTIiATI HAVE.015TRIBUOTHISINEORMATIONACCOROINGTOTHE <br /> 4'„ ' <br /> aISTR IS(ITION SH NON THE INSTAUCTION EET:O PAGE OF:THIS FORIuE <br />' REPORT nDATE7 CASE 0' <br /> 3 SIGNED ! <br /> NAME OF INDIVIDUAL FILING REPOR PHONE SIGNATOR <br /> 3Yco <br /> LU REPRESENTIN ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPAFIY OR AGENCY NAME <br /> RLOCAL AGENCY ❑ OTHER el- 49t�S t L(40 ; <br /> cc ADDRESS a; <br /> ^ ,,jj//�� �� S <br /> S STREET rf�Y l CjC7 �//r/� OrTY /�� /C�/� ;STATE TIP -. <br /> NAME gyp. CONTACT PERSON � PHONE <br /> z } �j/ _ - <br /> GCVr l //`t/Z'��I ❑UNKNOWN /f�Q/��� /L�Tiw` ��1�l T"- �,or /. <br /> O a ADDRESS <br /> a <br /> 4 /1# /y <br /> co <br /> UJ <br /> STREET Are-us CITYz d C% - ,:. STATE�IT yi <br /> FACILITY NAME(IF APPLICABLE) OPERATOR � PHONE <br /> 4 ADDRESS <br /> g —7:Z -7 doJ5 3�F <br /> y CROSS STREET COUNTY ZIP <br /> O LOCAL AGENCY AG£NCYJNAME CONN PERS�ON� ,^ PHONE } <br /> SS W <br /> Z1�S—� 4-0UJ <br /> aREGIONAL BOARD PHONE <br /> Gv�Lj 01(A 8!2�15 <br /> vi (I) NAME QUANTITY LOST(GALLONS), <br /> W p <br /> a Q 6 <br /> 1eLLL <br /> L�WI <br /> �'y �, ❑ UNKNOWN <br /> DATE DISCOVERED OW OISCOVERED ❑ INV ORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS- <br /> w 6M� I n Y ❑ TANK TEST ANK REMOVAL ❑ OTHER- <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> 5U F-1REMOVECONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING - (�• <br /> W <br /> U HAS DISCHARGE BEEN STOPPED? <br /> CD REPAIR TANK ❑CLOSE TANK S FILL IN PLACE ❑CHANGE PROCEDURE 1 <br /> C3 YES ❑ NO 1FYES,DATE mi Di Yl Y ❑REPLACE TANK; ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S)Ll r4; <br /> U, <br /> oU ❑ TANK LEAK UNKNOWN? ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL, <br /> y ❑ PIPING LEAK' ❑ OTHER ❑ CORROSIONNKNOWN ❑ OTHER w: <br /> LU wa CHECK ONE <br /> I�� UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER. ❑, DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ui NO ACTION TARN F PRELIMINARYSITEASS£SSMENTWORKPLANSUBMfSTED ❑ POLLUTION CHARACTERIZATION aF <br /> j ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS ; '!. ,'•.; <br /> V ❑ REMEDIATIDN PLAN ❑ CASE CLOSED(CLE/WUP COMPLETED UNNECESSARY) ❑ CLEANUP UNDERWAY w, <br /> CHECK APPROPRIATE ACTIONS) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) _ ❑ ENHANCED BIO DEGRADATION(IT) <br /> Q Ism amOk"AO ma? <br /> 5 p F7CCAP SITE(CD) ❑ EXCAVATE A TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)-❑ REPLACE SUPPLY(RS) <br /> w ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) F--1 TREATMENTAT HOOKUP(HL). ❑ VENT SOL(VS) <br /> 2 <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> r,. <br /> z �[/�71--Ael- L0f 1,pt <br /> v <br /> ui <br /> eow <br /> . _ ksc.asaa�w <br />