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' I qq. ,/ <br /> LJ- <br /> II�LL <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)1 C0NTAMFflOfStCQf <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FQKOCAL`AGENCx <br /> ❑ YES NO REPORT BEEN FILED 7 ❑ YES NO .;jHERf CERT(FY7FiA7l HA VEDWRIBU.MD,iHfS1NF iMAl10FfACf�f]Rp[NGTOhEE- <br /> AL5TF11BU T!(]IV 5F(04Nt[ON THIr IrlSTRUCTION 51iEE Ql1tE BACK PAGE OFTHr <br /> S3# S FORNL <br /> REPORT DATE CASE S s s <br /> 1 G X <br /> .i f d Tl <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNAAURE <br /> 6A vi A ck-_I ✓ <br /> w REPRESENTING OWNERioPERATOR ❑ REGIONAL 90ARO COMPANY OR AGENCY NAMEcr <br /> ❑ LOCAL AGENCY ❑ OTHER l ( (, <br /> a ADDRESS <br /> P,d, arc G� i+1 w CdAy /�P�°r �4;. �A ,���s7c)J rP <br /> w NAME OONTACTPERSON PHONE <br /> to T,}-- I ❑ UNKNOWN 12T)4f1 7-7 1 0 <br /> aa ADDRESS t /y J ,/' <br /> cr <br /> FACILITY NAME.(IF APPLICABLE) OPERATOR PHONE S <br /> .O � � - <br /> a ADDRESS <br /> a <br /> 1 ( 0 w, -F0AN R'�r 1-dA II � ODLwry <br /> y CROSS STREET - <br /> ✓ - <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z <br /> z AAA �pR Q - Mkt-AA/ C•ti'v u_ <br /> w REGIONAL BOARD PHONE <br /> Ll <br /> y NAME , OUANT(TYLOST(GALLONS) <br /> zZ w I LI[ �y UNKNOWN <br /> J <br /> L-- <br /> co? <br /> Z <br /> N ❑ UNKNOWN <br /> = DATE DISCOVERED HOW DISCOVERED ❑ .INVENTORY CONTROL ElTO <br /> SUBSURFACE MONIRING EDNUISANCE CONDITIONS <br /> Lu s Cu O o r ❑ TANK TEST �/ NK fAREMOVAL ❑ OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> cn <br /> Q UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> I d <br /> W - <br /> M <br /> p HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK CLOSE TANK 3 FILL llV PLACE ❑CHANGE PROCEDURE <br /> o YES ❑ NO IF YES.DATE O 3 f r r ❑REPLACE TANK Q UTHER <br /> SOURCE OF OL%WRGE CAUSE(S) <br /> ❑ TANK LEAK �NKNOWN ❑ OVERFILL ❑ flUPTURF/FAILURE SPILL <br /> 4 <br /> ca Q PIPING LEAK ❑ OTHER ❑ CORROSION 'UNKNOWN O OTHER <br /> Lu a CHECK ONE ONLY <br /> ❑ UNDETERMINED dSOIL ONLY ❑ GROUNDWATER' ❑ DRINKING WATER •(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK E ONLY <br /> U) 0NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> H 0 LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY Q POST CLEANUP mowrwtm I"PROGRESS <br /> ❑ REMEOL4T)ON PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑: CLEANUP UNDERWAY <br /> CHECK TE AC <br /> APPROPRIATIO N(S) ❑ K)DEGRADATION n) k <br /> EXCAVATE a DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED 9 <br /> ❑ <br /> Z E-1CAP SITE(CD) ❑ EICCAVATE a TREAT(ET) ❑ PUMP a TREAT GROUNDWATER(GTI REPLACE SUPPLY(HS) <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REOUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) VENT SUIT(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> Lu <br /> hISG 4'S ill . <br />