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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCYHAS STATE OFF OF EMERGESERV S FOR pG Y Y <br /> REPORT BEEN FLED 9 )}lERE C �}NAyE l�D7HI$INFORMq! ACCC�tDING TQTHE: <br /> E] YES El NO YES NO;❑ <br /> 17 ,THE: P O IN...FORM <br /> REPORT DATE CASES <br /> rw�- NAM <br /> E OF IV AL FL RT PHONEREPRES ING ❑ ® P OR <br /> Ir LOCAL AGE ❑ OTHER i91 y <br /> R <br /> Lu ADDRESS <br /> STATE ZIP <br /> PHONESTREET <br /> Lu NAME CON <br /> T TPE <br /> m ®UNKNOWN { ) <br /> F. <br /> aa ADDRESS <br /> w a `. `{ <br /> 2 ��� C,lyy STATE P <br /> FACILITY NAME(IF AP PLK:ABIE) AERATOR TPHCNE <br /> z <br /> O <br /> ADDRESS <br /> of STREEr cTl couNTv \�J P <br /> Lu <br /> CC- CROSS STREET <br /> p L L AGENCYE T T PER PHONE <br /> N *z { ) <br /> ,w <br /> \� <br /> w w REGIONAL B PHONE <br /> a a <br /> (') NAME QUANTITY LOST(GALL S) <br /> w <br /> p UNKNOWN <br /> w Y 1J <br /> dJ <br /> ®i (2) <br /> Z ❑ UNKNOWN <br /> N <br /> " DATE DISCOVERED HOW DISCOVERED F-1INVENTORY [:]/SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> z <br /> ® \ \ o r ❑, TANK TEST ❑ 7 OVAL OTHER i <br /> mDATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNK N E]REMOVE CONTENTS ®CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> Q M o v v <br /> > HAS DIS HARGE BEEN STOPPED T ®REPAIR TANK ®CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> YES ❑ No IF YES.DATE „\ 4 eQ- O r v E:]RE CE TANK OTNERY,Q\ Q <br /> SOURCE OF DI ESE(S) <br /> ❑ TANK U OVERFILL ® PTUREIFAILURE ❑ SPILL <br /> V ® PIPING LEAK F-1OTHERE:] CORROSION UNKNOWN ❑ OTHER <br /> w w CHE NE ONLY <br /> a a K WATER- E ONLY IF WATER. LS HAVE ACTUALLY BEEN AFFECTED) <br /> o UNDETERMINED ❑ SOLONLyGROUNDWATER <br /> CHECK ONE ONLY <br /> z ® NO ACTK)N TAKEN' ® RELIMINARY SITE ASSESSMENT SUBMITTED ® POLLUTION CHARACTERIZATION <br /> w <br /> a ❑ LEAK BEING FIRMED PRELIM RY SITE ESSM T UN RWAY POST CLEANUP MONITORINGIN PROGRESS <br /> V H ® REMEDIATION PLAN ❑ CASE CLOSED AEANUP COMPLETEDOR UNNECESSARY) ® CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ® EXCAVATE&DISPOSE(ED) ® REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> z ® tom CAPg ❑ E VATE T T ❑ PUMP TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w a ❑ CONTAINMENT BARRIER(CB) ® ACTON REOUIRED(NA) ❑ A AT P(HU) ❑ VENT IL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ <br /> OTHER(OT) <br /> r <br /> z <br /> w <br /> g <br /> U: <br /> -------------------- <br /> HSC 05 NN) <br />