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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />:: FOR LOCALAGENCY USE <br />❑ YES NO REPORT BEEN FILED ? ❑YES ❑ NO <br />j: IEREBY CERTIFY TN74T ! / I4 iia �� � <br />AEPQATEA THIS (NFCIHMA[ TO.#tpl. #RiH�SIIJtNT ftp SSCII�F ffibJJ� <br />TSE ANO: 00 <br />REPORT DATE <br />CASE # <br />o'13-1 zi qyi 3y <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE <br />(/ SJ'VTJ�V2L <br />m <br />( �� <br />LA A <br />w <br />REPRESEN ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br />a <br />' <br />❑ LOCAL AGENCY OTHER Cop �( UI4rj� .� <br />s <br />(��y��wus <br />�+ <br />q <br />ADDRESS -Alw <br />l il`c� llo coo -40 o- 4A- ��0 <br />661d�V� <br />STR ET CITY STATE ZIP <br />w <br />NAME <br />CONTACT PERSON <br />PHONE <br />zPwauds <br />UNKNOWN <br />1 f <br />¢ <br />d <br />w <br />�r ` ) <br />ADDRESS p. D sox X J 81 1 ►'1 alet ii c J4 I it • 01 <br />/" <br />cc w <br />STREET CRY STATE LP <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />PHONE <br />N <br />zi <br />O <br />V� <br />U <br />/�� {`'�, �� ADDRESS _js yvim-` SO 'j �OCI IA i �1 <br />J <br />w <br />STREET CRY COUNTY ZIP <br />a -i <br />CROSS STREET <br />TYPE OF AREA [Z COMMERCIAL O INDUSTRIAL ❑ RURAL <br />TYPE OF BUSINESS RETAIL FUEL STATION" <br />E:] RESIDENTIAL ❑ OTHER <br />❑ FARM ❑ OTHER <br />' <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />R4611 <br />t2 Y68 - X33 <br />W <br />fYjjnj0QQLA4, CL s�-v��� <br />w <br />REGIONAL BOARb <br />0 <br />PHHO/NE <br />%/, <br />1-54 <br />(t) NAME QUANTITY LOST (GALLONS) <br />tu <br />o <br />leJ ❑ UNKNOWN <br />to <br />v� O <br />(2) <br />❑ UNKNOWN <br />Z <br />DATE DISCOVERED <br />HOW DISCOVERED INVENTORY CONTROL F -]SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />0,) <br />E::] TANK TEST TANK REMOVAL ❑ OTHER <br />1 vY <br />r <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />w <br />d M D I Y y E] UNKNOWN <br />❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br />0 <br />❑ REPAIR TANK F REPAIR PIPING CHANGE PROCEDURE <br />HAS DISCHARGIfBEEN tTOPPED ? <br />pLANYES <br />' <br />❑ NO IF YES, DATE �M ODII <br />❑ OTHER <br />M D v y <br />LL' <br />SOURCE OF DISCHARGE <br />TANKS ONLY/CAPACITY MATERIAL <br />CAUSE(S) <br />U❑ <br />TANK LEAK ❑ UNKNOWN <br />GAL. FIBERGLASS <br />❑ OVERFILL n RUPTURE/FAILURE <br />QPIPING <br />LEAK <br />AGE YRS ❑ STEEL <br />❑ CORROSION T❑� UNKNOWN <br />❑ OTHER <br />O UNKNOWN ❑ OTHER <br />❑ SPILL ❑ OTHER <br />w w <br />CHECK ONE ONLY <br />v <br />❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />¢ � <br />5. SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />¢� <br />Urn <br />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 <br />CAP SITE (CD) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <br />2 $1 <br />ONTAINMENT BARRIER (CB) F7 EXCAVATE & TREAT (ET) F --]PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />¢ <br />❑ TREATMENT AT HOOKUP (HU) NO ACTION REQUIRED (NA) OTHER (OT) ++ <br />vr, w 40 <br />Ib 1 <br />8 <br />��� <br />I <br />HSC 05 (497). <br />9,+. <br />