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UNDERGROUND STORAGE.TANK.-UNAUTHORIZED RELEASE(LEAK)/,CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES AOR LOCAL'AGENCY'USE ONLY <br /> ❑YES /� REPORT BEEN FILED? ❑YES dN0 1;FIEREBY CERTIFY THAT I AM A OESIGNAT D GOVL}iNME(Vt EMF�LOY!E;11ND 7HAT:1 E-AVE <br /> [Ld }fit THIS'INFOFiMATiON,TCI LOCAVbff CIALS]PURSUA[IY TQ,SECTIO ;251., DF, <br /> REPORTOATE CASES THE ANDS <br /> }� f ', <br /> NAME OF INQJVIDUAL FhINQ REPORT_ PHONE SI N TURE <br /> - 8y <br /> d3 REPRESENTING OWNE WQPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> pOCAL AGENCY .❑ OTHER <br /> ADDRESS v <br /> STREET _ QTY STATE +• ZIp <br /> NAME f, �I CONTACT PERSON <br /> V)� I�O Y PAT i �" UNKNOWN PHONE <br /> Z Ir ADDRESS ❑ <br /> �a S.Z� /fir � <br /> 37REE7 ` CITY t <br /> - � STATE pp <br /> FACILITY NAME IFF'APPPLLII1CABLE) rJ' OPERATOR <br /> - a'HQNE: <br /> U4 ADDRESS J/�7 .. _ - 116S -riW_ <br /> Q •�, `. G R ,. � <br /> J <br /> �!1 - T <br /> cri .••CdJHTY <br /> y CR S STREET _ TYPE OF AREA ' <br /> COMMERCUIL❑INDUSTAIAL❑RURAL TYPE OF BUSINESS <br /> [(/ ^� ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ 0711 R RETAIL FUEL STATION <br /> LOCAL A ENCY AGENCY NAME Cp TAGT PERSON PHONE.. <br /> REGIONAL BOARD PHONE <br /> t 1 ! <br /> () NAME QUANTITY LOST(GALLONS) <br /> X (2) UNKNOWN <br /> ❑ <br /> �- DATE OI VEREQ HOW DISCOVERED UNKNOWN <br /> r ❑ INVENTORY CONTROL ❑ SUBSURFACEMONITORING.. . ❑ NUISANCEOONDITIONS <br /> I ❑ <br /> TANK TEST _ TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN <br /> Y Y GAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> u M b o v rUNKNOWN 1 I ❑ REMOVE CONTENTS ED REPLACE TANK " CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? +' F!V '+ ❑_REPAIR TANK ❑ 'REPAIRPIPWG W <br /> �❑ CHANGE PROCERE <br /> ❑ YES ❑ NO IF YES.DATE ❑'^'OTHER r' ' <br /> SOURCE OF DISCHARGVUKNOWNl0000lfiolo, <br /> TANKS ON iCAPACITY .,.I MATERIAL y CAUSE(S) <br /> ❑ TANKLEAK DISCHARGE <br /> DAL. ❑ FIBERGLASS [D OVERFILL ❑ RVPTURE/FAILURE <br /> /I Ic z! <br /> ¢ ❑ PIPING LEAK AGE :.YRS ,.`• 'STEEL . �❑ CORROSION UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN r• OTHER <br /> 0 SPILL ❑ OTHER <br /> Lu Lu CHECKONEO - i <br /> UNDETERMINED ' <br /> ❑ SOIL ONLY ❑ GROUNDWATER O DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED l <br /> F CHECK ONE ONLY <br /> a ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT DOR06LEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> pNO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED <br /> ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK AP.ROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> E5 o E5 x CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP)' E:] EiVHANCED BIO DEGRADATION(IT) <br /> ❑Lu P <br /> CONTAINMENT BARRIER(Ce) ❑ EXCAVATERTREAT(ETj� ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENTAT HOOKUP(HU) ❑ NO ACTION REOUIRED(NA) ❑' OTHER(OT) <br /> .; u;7 <br /> NSG OSµ.e11 <br /> I <br />