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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGE SERVICES FOR LOCALAGENCY USE ONLY <br /> REPORT BEEN FLED 7 THEREBY"CERTIFY THAT LAM* OESiGNATED GdVERNMENT EMPLOYEE AND THAT I HAVE: <br /> ❑YES NO YES ❑ NO .:REPORTED:THIS.INFORMATIOWTO LOCAL CFFICIALS PURSUANT TO SECTION 25t8Q10F <br /> REPORTDATE //� p V , CASE 7e <br /> CEJ THE HEAD ANO CODE y� g <br /> ( V ;.SIGNED .: <br /> Y <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SI <br /> > a,(2/ ©? j�D� S/(o 3v687%�-m COMPANY OR AGENCY NAME <br /> w REPFlESENTI ❑ OWNER/OPERATOR ❑ REGIONAL BOARD ` CS <br /> aJ <br /> O LOCAL AGENCY ❑ OTHER �in TVcc i,u/n con .�u <br /> a <br /> Q ADDRESS / <br /> Ile- z e. STREET CRY STATE 2P <br /> 14 NAME /� /� CONTACTPERSON PHONE <br /> H s G n KC Gl/�lf. ❑ UNKNOWN \7,-e.-,?es TXo r-7 CCs -3 <br /> a ADDRESS 1 C 33(0 <br /> CSL!/SC y.�EET cm STATE t194 ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS <br /> CITYrin TL c� ..TY P <br /> ~ < ` EEr COMMERCIAL❑INDUSTRIAL❑RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> C S STREET <br /> v7 TYPE OF AREA <br /> ❑RESIDENTIAL Q OTHER a FARM Q OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> REGIONAL BOA PHONE <br /> (1)Lu <br /> NAME QUANTITY LOST(GALLONS) <br /> g �f� /c ! 1 U ,G1 Q U/N�NowN <br /> ❑ UNKNOWN <br /> DATE DISCOVERED Y Y �❑S� ED TEST ❑ TANK REMOVIRY AL ❑ OTHERROL MONITORING ❑ NUISANCE CONDITIONS�u M M O D <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> "UNWN ❑ REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> �y M M D 0 Y Y <br /> > Q REPAIR TANK REPAIR PIPING CHANGE PROCEDURE <br /> IHAS DISCHARGE BEEN STOPPED? <br /> o ❑ YES ❑ NO IF YES.DATE D ❑ OTHER <br /> M M o v r <br /> w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> 25 4 ❑ TANK LEAK UNKNOWN 2 GAL. ❑ FI S ❑ OVERFLL Q RUPTU AZURE <br /> ❑ PIPING LEAK AGE YRS STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w w CHECK ONE ONLY <br /> a <br /> ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> a ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> IN <br /> cc <br /> V ti ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 4 z ❑ CAP SITE(CD) ❑ EXCAVATE 3 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> wREAT(ET) <br /> ❑ PUMP 6 TREAT GROUNDWATER(GT) a REPLACE SUPPLY(RS) <br /> 2� ❑ CONTAINMENT BEXCAVATE 8 T ( <br /> BARRIER(CB) ❑ <br /> a TREATMENT AT HOOKUP(HU) ❑ NO ACTION REOUIRED(NA) ❑ OTHER(OT)` <br /> eess es c w.!/ �i A e crs sez, � �?'c-Ai`i,l.Y •�zu cc�-�c v- �,c '.,� <br /> z <br /> ui <br /> HSC050471 <br />