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Rue <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL'AGENCY USE ONLY... <br /> 0 YES RrNp REPORT BEEN FLED? (�YES Q NO 1 HEREBY CERTI�THAT J AM A DE$IGNATEQ GOVERNMENTEMPLOYEE AND THAT4.HAVE <br /> Y�-� REPORTED:THIS.7 INFORMATION.;TO.tOCAL_,OFFl W0::Pt1ASUMlT.70...SECT 180.7 OF <br /> REPORT DATE CASES THE HEALTH AND SLATY ! <br /> �MI M o d y v .SIGNED ;:..... DATE <br /> N E OF INDIVIDUAL FILING REPO//RT PHONE SIGNATU <br /> (;'S) <br /> REPRESENTING OWNERIOPERATOR O REGIONALSOARD COMPANY((OR/AGEN / <br /> O <br /> cc <br /> LOCALAGENCY OTHER SiJ �(� • �.1T <br /> a <br /> cc 7,RESS CA <br /> o- C- ( 0 CITY Y STATE ZIP <br /> Lu NAME nn' =ERSON PHONE <br /> ZQ' UNKNOWN �r V ) -[ Y <br /> Q�/ <br /> Od <br /> 6' L- <br /> Ra DRESS <br /> S7REET CITY STATE ZIP <br /> FACILITY NAME(IF PLICABLE) OPERATOR PHONE <br /> a ADDRESS {., �--. <br /> r L� 54dE y �-71b tu'`/ C-A_ y 9�,ar <br /> ZIP <br /> F CROS TRE T TYPE OF AREA [j:!f-t6MMERCIAL a INDUSTRIAL 0 RURAL TYPE OF BUSINESS O RETAIL FU L STATION <br /> 0 RESIDENTIAL F--]OTHER FARM [ -OPER <br /> LOCAL AGENC AGENCY NAME CONTACT PERSON PHONE <br /> p� <br /> zW c if-)q6 . �, <br /> w Lu <br /> w REGIONAL BOARD PHONE <br /> (1) ` <br /> NNAME OUANT(TY LOST(GALLONS) <br /> NJ ,',DD// <br /> w O (�t/L� i11�`� <br /> KNOWN <br /> 0 (2) <br /> �- <br /> a UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED O INVENTORYCONTROL0 SUBSURFACE MONITORING 0 NUISANCE CONDITIONS <br /> M M D o v y 0 TANK TEST �TANK REMOVAI.>D,"C O OTHER <br /> D�AyTE DISCHARGE BEGAN QQ METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w !�M M b o �o U v y 0 UNKNOWN REMOVE CONTENTS 0 REPLACE TANK CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? � REPAIR TANK F7 REPAIR PIPING CHANGE PROCEDURE <br /> o YES a NO IF YES,DATE yM 5 MI o V,xC v v OTHER J <br /> w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> O TANK LEAK �NKNOWN S�U�a GAL. FIBERGLASS OVERFILL RUPTURE/FAILURE <br /> Cc O PIPING LEAK AGE YRS STEEL CORROSION ©--'UNKNOWN <br /> 2 O OTHER TfrUNKNOWN O OTHER SPILL O OTHER <br /> w w CHECK ONE ONLY <br /> UNDETERMINED O SOIL ONLY GROUNDWATER O DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) O CLEANUP IN PROGRESSO SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> rn WWO- NO ACTION TAKEN O POST CLEANUP MONITORING IN PROGRESS O NO FUNDS AVAILABLE TO PROCEED �ALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> z O CAP SITE(CD) a EXCAVATE 8 DISPOSE(ED) O REMOVE FREE PRODUCT(FP) O ENHANCED BIODEGRADATION(IT) <br /> w� CONTAINMENT BARRIER(CB) O EXCAVATE&TREAT(ET) O PUMP&TREAT GROUNDWATER(GT) O REPLACE SUPPLY(RS) <br /> O TREATMENT AT HOOKUP(HU) O NO ACTION REQUIRED(NA) O OTHER(OT) <br /> U) <br /> z <br /> z <br /> w <br /> c <br /> MSCOS(4R'n <br />