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1. <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HASSTATE OFFICE OF EMERGENCY SERVICES <br /> I FOR LOCAL4GENCY USE ONLY:; <br /> I YES �j_,'� REPORT BEEN FA ED 7 ED YES <br /> k 3lERY SRT! <br /> L� " T E AM A pi StGNATEO GQVEN„ EM IYEE ANA THA?1 HAVE <br /> ftEPORYED T#3 fOHMATtON TO OFF RSl} SECTIpN 2514U.'I OF <br /> i� REPORT DATE CASs THEHEAL SAI-IT D7= <br /> NAME OF INDIVIDUAL FILING PORT SIGNATURE <br /> r <br /> i <br /> k REPRESENTING OWNER+OPERATOR ❑ REGIONAL BO RD COMPANY ORAGEN <br /> ir LOCAL AGENCY OTHER <br /> r <br /> ADDRESS <br /> clrr srArr: <br /> �l NAME CONT TPERSON PHONE n <br /> 1�rllwowN <br /> La <br /> a <br /> ADDRESS <br /> tT � <br /> FACILITY NAME(IF APP <br /> LX: OPERATOR PHONE <br /> ADOF 74b I <br /> y CROSSSTREET TYPE OF AREA&<rCOMM ERCIAL ❑INDUSTRIAL ❑RURAL TYPE OF BUSINESS <br /> RETAIL FUEL STATION <br /> ra rjo L'loj ❑RESIDENTIAL ❑OTHER ❑ FARM ❑OTHER <br /> LOCAL AGENCY t AGENCY NAM CONTACT PARSON PHONE <br /> REG BOARDk PWNE <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> ®,UNKNOWN I <br /> i ❑ UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL pRT-SUBSURFACE MONTTORNG NUISANCE CONDITIONS <br /> oy 3M o o r r ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> u N n v v ®—UNKNOWN ❑ REMOVE CONTENTS REPLACE TANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED 7 f/ _ ❑ REPAIR TANK REPAIR PIPING fRCHANGE PROCEDURE <br /> a ❑ YES E:] No IF YES.DATE u w o v v ❑ OTHER <br /> SOURCE OF DISCHARGE TANKS LYrCAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK P!�J­UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL i� ❑ RLPTURE)FAILURE <br /> PIPING LEAK AGE YRS ZQ-'&qEEL ❑ CORROSION-1 UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER <br /> ❑ SPILL ❑ OTHER , <br /> w CHECK ONE ONLY <br /> ❑ UNDETERMINED a SOIL ONLY JNT GROUNDWATER DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> cr c 2<SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> c�d' ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PRDGRESS ❑ NO FUNDS AVALABLE TO PROCEED ❑ EVALUATING CLEANuP ALTERNATIVES <br />'} CHECK APPROPRIATE ACTION(S) <br /> (SEE BACK FOR DETAILS) , <br /> ❑ CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) CBPTT*N(IT) <br /> Lu <br /> ❑ CONTAINMENT BARRIER(CB) EXCAVATE3 TREAT(En ❑ PUMPs TREAT GROUNDWATER <br /> TREATMENT ATHOOKUP(HU) NO ACTION REQUIRED(NA) ❑ OTHER(01) <br /> x <br /> . 17 <br /> testi > '.l �_ {`� ( Slt r > J3, Yl4" ° _ , ?A "' "' 'x -• Y"'.L:,�F'iC Yx ',�"'d-y`� - } <br /> 5 <br /> .� � � �. ?`"r*�x� <br />