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UNDERGROUND STORAGE TANK UNAUTHORIZ D RELEASE(LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SE FOR LOCALAGENCI(USE ONI;Y <br /> REPORT BEEN FRED 7 E�(ItRE81({ RT 7(AM A tSIGI�II? G`Q ?IVIE 11N� T 11111i . <br /> YES No ❑YES No .:R�PgflTEEI't. ...:FORMhT)DN'FO;....-..'_: ,:)GINS f'�1t?SU.AF)T:Ta.SECT�lN.;25tAnJ'OF. <br /> REPORTDATE CASES <br /> u u ! o r r SK,taED. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNrUV/ � 1 �3y4 <br /> REPRESE G ❑ OWNERIOPERATOR ❑ REGIONALBOARD COMPANYORAG!�NAME _ 1 <br /> a <br /> LOCALAGENCY ❑ OTHERfl U[/ Vd WSJ f ALJ �V 1�Y G <br /> ADDRESS <br /> STREET �h-✓ errr �S% rcJ STATE ,4v <br /> ys�a� <br /> NAME CONTACT PERSON PHONE 5-10y- <br /> (L <br /> ,Q� ❑ UNKNOWN (,20 NI d�) Q'b ( 5-10 <br /> a ADDRESS <br /> L44 <br /> sTREET C:'V�1%t urr STATE VP <br /> FACILITY NAME(FAPPLICABLb) OPERATOR PHONE <br /> ADDRESS <br /> STREET � ySa� <br /> rsrr caaKTr <br /> CROSS STREET TYPE OF AREA COMMERCIAL❑INDUSTRIAL RURAL TYPE OF BUSINESS ETAIL FUEL STATION <br /> E-]RESIDENTIAL (:3OTHER ❑ FARM IEA <br /> �y LOCAL AGENCY AGENCY NAME - - CONTACT PERSON L PHON, <br /> 2� r <br /> w W _ •' � <br /> REGIONAL BOAW <br /> PHONE/ <br /> {1) NAME QUANTITY LOST(GALLONS) <br /> � NKaNOWN <br /> (z) <br /> �- '` owN <br /> DATEDiSCO RED 49HOWDISCOYEREO ❑ I RYcoNTROL ❑ SUBSURFACEMONITORM ❑ MISANCECONDITIONS <br /> M •M Qo o r ❑ TANK TEST ANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALLTHATAPPLY) <br /> rS` <br /> ul mi X. DI Yl <br /> El-UNKNOWN ❑ REMOVECONTENTS ❑ REPLACETANK ❑ CLOSETANK <br /> HASD GE BEEN STOPPED? ❑ AIR TANK ❑ REPAIRPIPI IG ❑ CHANGE PROCEDURE <br /> p YES ❑ NO FYES,DATE ! u Q� o r r L� OTHER -- <br /> t� .SOURCE OF DISCHARGE TANKS ONLY)CAPACITY MATERIAL CAUSE(S) <br /> M C3 TANK LEAK UNKNOWN GAL ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREIFALURE <br /> ❑ PIPING LEAK AGE YRS STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER NKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> Lu CHECKONEONLY <br /> ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ ORINKI NG WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY SEEN AFFECTED) <br /> CHECK ONE ONLY <br /> a ❑ SaTE WVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP LETEDOR UNNECESSARY) <br /> E:] NO ACTION TAK£N ❑ POST Ca.£ANUP MONRP( <br /> ORG)N PRDGRESS ❑ NO FUNDS AVAILABLE To PROCEED VALUATING CLEANUP ALTERNATNES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAL% y , <br /> ❑ CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT{FP) ❑ ENHANCED SKS DEGRADATION(IT) - <br /> ❑ CONTAINMENT BARRIER(CS) ❑ EXCAVATE&TREAT(ET) ❑ PUM TREATGROUNDWATER(GT) ❑ REPLACESUPPLY(RS). <br /> ❑ TREATM ENT AT HOOKUP(MJ) ❑ NO ACTION REQUIRED(NA) OTHER(OT) F` <br />