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9C�-- U <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)!CONTAMINATION SITE REPORT <br /> EMERGENCY /' HAS STATE OFFICE OF EMERGENCY SERVICES OR LOCALAGENGY USE ONLY <br /> ❑ YES NO REPORT BEEN FILED T YES NO HERESY CER7IFY3HAT t AM/►DES)C,NA7EA GOY�(tJENf EMPLOYEE AkND �HAf I HAVE. <br /> D O REPORTED THIS fNFOFiMAT10N:TO aFF)c)us PURSt)MET 7 sEcrtoN 25)80.7 OF <br /> REPORT DATE CASE THE H TH AND SAFTY <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> 0 REPRESENTING low ❑ OWNERIOPERATOR ❑ RVIGIONAL BOARD CAMPANY OR AGENCY NAME p6alle, <br /> LOCAL AGENCY ❑ OTHER <br /> O % T SAV <br /> CL <br /> Lu <br /> cc ADDRESS( <br /> YiV Q STREETV01 CITY� OQ <br /> n A/ SPATE <br /> NAME n y /� �J� CONTACT PERSON �r I/ IAte- � / PHONE Q2/ <br /> z V �'1 Q /' �/�'rTL ❑ UNKNOWN o/V A' G, MA50t 1!J'� U -3 J <br /> R d ADDRESS /� /�!�(f - <br /> U L/ srREET V vv cm sr�TE 46-� �+ p/ " <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHOT <br /> ADDRESS A� coum" / <br /> W /`' " sTREET J� CRY 9�p /•V <br /> y CROSS STREET(r (/ TYPE OF AREA ❑COMMERCIAL INDUSTRIAL❑RUR TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> '� ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME) NTACT PERSON PHONE [�` <br /> z w .�' �^ Il G ( ) l (08-3 <br /> W <br /> w REGIONAL BOARD� PHONE <br /> a. <br /> y (t) NAME QUANTITY LOST(GALLON <br /> LU o <br /> w e,K �a `�MJ�► v UNKNOWN <br /> 0 (z) <br /> w+ ❑ UNKNOWN <br /> z DATE DI VERED HOW DISCOVERED ❑ NTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 0. A �o o F p Y = TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M DI DI Yl Yl ❑ UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED Z PAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> ❑ YES ❑ NO IF YES,DATE M MI DI 01 YJ y L OTHER `y rg,(-a.d 1,14 <br /> w SOURCE OF DISCHARGE TANKS ONLYiCAPACIITTYY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN 3So �%v � ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAiLURE <br /> Q ❑ qy <br /> PIPING LEAK AGE j YRS ❑ STEEL ❑ CORROSION ❑ UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> LU w CHECK ONE ONLY <br /> V ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONS ONLY <br /> z� <br /> 2< ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> V rn ❑ 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 /> z ❑ CAP SITE(CD) ❑ EXCAVATE 3 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> do <br /> ui <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) OTHER(OT) <br /> y <br /> r76i Yc5 1,4 1,494-10-1V <br /> W ,ep� o �c/ S—/j/--�!a G✓/E/LP� C Z� f/•�/o/pic y r�u �s <br /> -� dkr K/Lo/'e f'�iw-o ✓e./ �✓ J SS , ��,r,2�P,e si.`� assrss <br /> 6vi L L he 74%e <br /> Gv ,v 7,4 M-�,J l/ P. a�O,�"Plvp r•/,4 <br />