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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICE, QR=ALIAGENCY;:USE QNLY <br /> E-1 YESVNO REPORT BEEN FLED? ❑ YES NO #'HEREBY CERTIFY,TE AT E AM A DE$1wTED GOVEE NMW4 EMPLOYEE <br /> IINFOHMAT)ON <br /> ts aFF�cuus PUTANr TCk scnaN 25,adi of <br /> REPORT DATE CASES THEH AND <br /> (/MI 60'. Y SIG ED .....r. <br /> :.: .. ..:.: ::.r... <br /> NAME INDIVIDUAL FILING REPORT PHONE AGN <br /> } 68-3V( <br /> w REPRE !NG ANY OR EN <br /> NAME <br /> OWNERIOPERATOR REG,ONALBOARD <br /> LOCAL AGENCY ❑ OTHER / <br /> 7 7,� <br /> ¢ ADDRESS <br /> love- <br /> STREET CITY STATE ZP <br /> y� ME CONT TPERSON /PH�O,N,E,{ �y7 <br /> z¢ ,W 7 I ❑ UNKNOWN /Ke 1 ji�[J�yl S� —CJ e�J <br /> cc <br /> a 2 ADDRESS <br /> LLI <br /> -2P01 <br /> STATE <br /> FACILITY NAME(IF APPLIC:B ) OPERAjOR PHONE <br /> ADDRESS p/y <br /> J I V <br /> STREET CITY COUNTY12 ' <br /> CR STREET TYPE OF AREA ❑COMMERCIAL� STRIAL[:3 RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> orl'- W I ❑RESIDENTIAL ❑OTHER ❑ FARM Q-OMER <br /> L LAGENCY[ AGENCYNAME CONTACTPEASON PHONE <br /> L2u REGIONAL BOARD PHONE <br /> CL <br /> (,) NAME OUANTRY LOST <br /> � O f LU UNKNowN <br /> (2) <br /> y J ❑ UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> D M lL M Q o p <br /> RY-1 gy ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN j METHOD USED TO STOP DISCHARGE(CHECK ALL THATAPPLY) <br /> m M M oII r v <br /> 1NKNOWN CEr-RE MOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> HAS DISC ARGE BEEN STOPPED? NG <br /> ❑ REPAIR TANK ❑ REPAIR PIPNG ❑ CHAE PROCEDURE <br /> 4 YES ❑ NO IFYES,DATE MI p ofOTHER �1�i�ldyQ <br /> Lu SOURCE OF DISCHARGE TANKS ONLYr-APACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK C UNKNaWN GAL ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREIFAILURE <br /> 0 F-1PIPING LEAK AGE YRS EgEE0 CORROSION OWN <br /> cc <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> I <br /> LU Lu a CHECK ONE ONLY <br /> v ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED► <br /> e <br /> r CHECKONEONLY <br /> zewc of <br /> a ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cc I- <br /> ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITOR ING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 0 0 ❑ CAP SITE(CD) ❑ EXCAVATE a DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION on <br /> w ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE E TREAT(ET) ❑ PUMP 6 TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> CE ❑ TREATM ENT AT HOOKUP(HU) ❑ NO ACTK)N REOUIRED(NA) ❑ OTHER(OT) <br /> 5/te ASS�Ss'/x�ic. be U) j�u- u <br /> 'y4- ��-� <br /> "sc as f�71 <br /> L <br />