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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMEFE3ENC1f FW STATE OFFICE OF EMEROENCVSERVICE' ;`fit a •: s 't3 't u� <br /> YEsNO t a w <br /> ttt ❑ ff D YES <br /> REPORT BEEN FLED r "" <br /> it REPORTDATE CASES <br /> 0.4 <br /> OF*=vwUAL Rm REPORT PHONE pE - <br /> REP WERATOR ❑ REGIONAL BOARD COMPAMP O-R <br /> AMMOMM <br /> AGENYQ �a AGENCY �E <br /> . <br /> re <br /> AOTPE PHONE <br /> d <br /> Annwjc <br /> Gid `1 2-Alb <br /> FACLIITY'NAME Ey ` 70R PFDPE <br /> ADDRESS "4 ! 1%pbu <br /> xTRmdF TYPE OF AREA COMMERCIAL❑N XMTRALRURAL TYPEOFSUSINESS RETALFUELSTATO7N <br /> ❑RESIDENTIAL ❑OTHER ❑FARM <br /> LOCALAOENEN AGENCYNAME ACTPERSON (plq <br /> REOIONALBOARD <br /> (�) NAME OUANTTTY lOBT <br /> � _ UNRIOYNN <br /> DJITE D�1,6{CaVEpEO FLOW DISCOVERED � OOFDITTONS <br /> 8T TANKTE �O <br /> E � TANK REMOVAL <br /> t` DATE DISCHARQE BEOIW METHOD USED TO STOP DISCHARGE(CHECK ALL TWIT APPLY) <br /> •' w g'UWWOWN ❑ REMOVECONTENTS ❑ REPLACETANK EKQMETANK <br /> IMS DISCHARGE;NOFIYESJGATE <br /> N Pin? ❑ REPAIR TANK ❑ REPAIR PFM ❑ CHANGE Pnocey n <br /> 0 YES _ 0 ❑ OTHER <br /> SOURCE OF OISCHNARGETANKS ONLYVICAPACITY MATERIAL <br /> ❑ TANK LEAK �U'WNOWN XQo A't) GAL. Q FIGE11M ASS a OVERFILL ❑ RUPTUREA ALuraE <br /> PIPING LEAK AGE YRS �TEEL ❑ CORROSION [Kp/Wo OWN <br /> OTH ER OTHER ❑ SPIM ❑ OTHER <br /> CHECK ONEOWY <br /> TERMED ❑ SOL ONLY ❑ GROLM (NATER ❑ ORI KING WATER-(CHECK ONLY IF WATER WELLS HAVE ACRIALLY BEEN AFFEC1110) <br /> !q <br /> CHECK ONE ONLY <br /> ❑ SITE NVESTKIIATION N PnOORESS MINING EXTENT OF PROBLEM) ❑ CLEANW IN PROGRESS❑ M*JED OFF P.EAMF COMPLETED OR L&MECESSARY) <br /> E °� ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING N PROGRESSNO FUND$AVALABLE TO PROCEED <br />( ❑ L21EYALUATWG CEAPIIP ALTERNAITVEB <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(co) ❑ EXCAVATE a DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED S)O DEm;ADATIM(M <br /> t� ❑ CONTAINMENT BARRIER(CO) EXCAVATE i TREAT(ET) ❑ PUMP 8 TREAT OROUNDWATER(OT) REPLACE SUPPLY(RS) <br /> ❑ TREATMEMATHOOKLIPOM ❑ NO ACTIONREOWREDO" ❑ OTHER(0-4 <br />