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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION S1 T <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES AOR LOGAL/iGENGY:USE ONLY.....: >:.... .. :: ....:. <br /> ............................................................................................................................................... <br /> ❑ YES NO REPORT BEEN FILED? E]YES ❑ NO #(�R61`CERT)fYTHAT B AN) D $IGNA3p ....0 MINT EMPLpY AN4 THAT E HAVE <br /> REPORTED.: THE� , . ... :PURSUANT TO.SECT(ON:25a607�;F <br /> REPORTDATE CASES � #( <br /> al '17Di r v SIGry <br /> 1TE; <br /> .. ... <br /> NAME OF INDIVIDUAL FILING REPORT PHONECk <br /> SIG <br /> «� r <br /> ® S ) <br /> w REPRESENT G ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> ¢O OCALAGENCY ❑ OTHER �° <br /> a t <br /> Q ADDRESS ( <br /> STREET CITY STATE ZIP <br /> NAMETACT PERSON PHONE <br /> Ds0 <br /> ❑ UNKNOWN ) <br /> Q ADDRESS <br /> a. <br /> KVAl, C Ifig-4 STREET '� CITY STATE ZIP <br /> FACILITY NAME(IF AP LICA lE) OPERATOR PHONE <br /> q ADDRESS <br /> STREET CRY COUNTY MP <br /> CROSS STREET TYPE OF AREA ❑COMMERCIAL a INDUSTRIAL❑RLIRAl TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> yo-f a RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> W L2u 'i joaquid &A41 A h!r. ) <br /> W REGIONAL BOARIS <br /> (PHONE <br /> y (1} NAME QUANTITY LOST(GALL ) <br /> UNKNOWN <br /> W <br /> M— <br /> UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ VENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> M M o o y y ❑ TANK ST TANK REMOVAL E] OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w <br /> MI MI DI 01 Yl yl EZ/UNKNOWN ❑ REMOVE CONTENTS F-] REPLACE TANK CLOSE TANK <br /> HAS DISQHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p YES E-] NO IF YES,DATE Al p D y y ❑ OTHER <br /> wSOURCE OF DISCHARGE TANKS ONLYICAPACITY MATERIAL CAUSE(S) <br /> D ❑ TANK LEAK UNKNOWN GAL. ❑ F BERGLASS ❑ OVERFILL ❑ TURE/FAILURE <br /> ❑ PIPING LEAK AGE YRS STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w CHECK ONE ONLY <br /> v ❑ UNDETERMINED ❑ SOIL ONLY a GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F- CHECK ON:ONLY <br /> a ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CI EANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> V ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS E] NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> o O ❑ CAP SITE(CD) F-] EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA)® O OTHER(OT) <br /> ��� e fl � 9 � CL9 ✓ 9� <br /> wed ' <br /> HSC05(4B7) <br />