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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR <br /> ❑ YES NO REPORT BEEN FILED? YES NO 1''HEREBY;CERTIFYAHAT)'AM A OESI.dl T D GI]VERNMENT:.EMK0YEE AND THAT'(HAVE: <br /> (� :,SEPORTEDTHlS INFORh1ATION>:TO LACAE:OFF(CIAiS PUHSI�AiVT TO:.SECT(ON.251807 OF. <br /> REPORT DATE CASE$ THE kEALTH AND SAFfY 1xYUE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGN E <br /> r <br /> o REPRESENTING OWNERIOPERATOR REGIONALBOARD COMPANY OR AGENCY NAME 1 <br /> cc o LOCAL AGENCY OTHER I I C - .r�� ( �, 'r (�Ipn,COE <br /> ADDRESS(oC) ) ` i 1 I Z.�'L��I/ i■ f j�Li�� ��� q- J <br /> 111 ��`'Y— <br /> STREET CIT/ STATE ZIP <br /> NAME CONTACTPERSON /PHONE <br /> y �G <br />_ zQ V L ❑ UNKNOWN <br /> g 4a ADDRESS <br /> L. �,��0 STREET CRY STATE �. ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> z <br /> ill - rtil r _ ; f�o�1 c L/ <br /> q ADDRESS <br /> J <br /> STREET CITY COUNTY mv - <br /> yCROSS STREET TYPE OF AREA COMMERCIAL INDUSTRIAL RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> RESIDENTIAL ❑OTHER FARM Q OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACTPERSON PHONE <br /> en <br /> L- G G <br /> Lu REGIONAL BOARD / PHONE <br /> cn 11) NAME QUANTITY LOST(GALLONS) <br /> �w O UNKNOWN <br /> � - I Y�sZ� <br /> En ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> M M 0 <br /> .1 <br /> [Y C� oy ❑ TANK TEST TANK REMOVAL 1 OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> cu M M o DI V1 v <br /> UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> } HAS DISCHARGE BEEN STOPPED? //�1 l�1? El REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> 4 YES Q NO IF YES.DATE M t r►� ��)o o Qv Imo_ OTHER ' >� <br /> II w SOURCE OF DISCHARGETANKS ONLYICAPACITY MATERIAL CAUSE{S) <br /> D TANK LEAK I S I UNKNOWN GAL. Q FIBERGLASS E:] OVERFILL RUPTUREIFAILURE <br /> cc El PIPING LEAK '"� AGE YRS kTEEL ❑ CORROSION UNKNOWN <br /> OTHER `UNKNOWN OTHER ❑ SPILL ❑ OTHER <br /> w w CHECK ONE ONLY <br /> i v ❑ UNDETERMINED rEg-SOIL ONLY ❑ GROUNDWATER DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ¢a Q SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cr <br /> V H 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 /> 1 z ❑ CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(11) <br /> 1111 ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE d TREAT(ET) ❑ PUMPS TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) 1 <br /> TREATMENT AT HOOKUP(HU) a NO ACTION REOUIRED(NA) OTHER(OT) <br /> l`��L.�/L �/�J Iii�i-�t-:ter/��r�:Y. GV//! fin (C-L�1✓' -sof/ �� del.�',,--��Z.L�:---(_ // r J <br /> t! •1LLu <br /> •1_..�-iv1 /i I"•..r G,: •��-.r% i` r ,f:: .rr <br /> LLL 1 <br /> S NSG 05("m <br />