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• <br />• <br />HSC 05 (444, <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LgCALAGENGIf USE ON4Y <br />❑ <br />YES NO REPORT BEEN FILED ? DYES 3 HEREBY` QERTTIFX 7 [ <br />T GQifEANMEtVT I4IP( ®YEE. R TI�AT: E k(AAif <br />1EPORTEDIHIS <br />AL #F[C(1L PURSUAPiT TO SES TIMI oF; <br />REPORTDATE CASES THE#iEAtTHAN(7 �` <br />®M <br />p <br />IM O ` <br />D <br />i�tTE <br />' '.:::.. <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE SIGNATURE <br />m <br />av`4 C <br />a <br />REPRESENTING ❑ OWNERlOPERATOR ❑ REGIONALSOARD <br />COMPANYORAGENCY NAME <br />w <br />E <br />LOCALAGENCY ❑ OTHER <br />¢ <br />DDRESS <br />rlo`E. ��G' Q c�` SIE �-a7 <br />CA Sze t <br />BEREFT T CITYSTATE <br />ZIP <br />ul <br />NAME <br />CONTACT PERSON <br />PFONE <br />u�i ¢ <br />C v S ��Mh t er ❑ UNKNOWN <br />et�V. oL'4a s ®v+ <br />y <br />3 T �A.S®' 669 <br />T <br />a <br />cc <br />ADDRESS <br />yus -+ No _% <br />LA <br />STREET CITY <br />STATE -. p <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />PHONE <br />®ed s <br />Ua <br />O <br />ADDRESS 1g p <br />Is W JayltiKQ d. YAc <br />a►.QA�,`e h�(S 3}fo <br />. <br />STREET CITY <br />COUNTY <br />rn <br />CROSS STREET <br />TYPE OF AREA COMMERCIALE:] INDUSTRIAL [::]RURAL <br />TYPE OF BUSINESS F7RETAIL FUEL STATION <br />0 RESIDENTIAL ❑ OTHER <br />FARM ❑ OTHER <br />ZLOCAL <br />AGENCY AGENCY NAME 11 <br />k :loA Loc—I e� t�Li <br />CONTACTPERSON <br />PHONE <br />vel 1STJs t <br />utd I..A& <br />cZaoj, y4+F�3 e�40 <br />LLu <br />REGIONAL BOARCr <br />PHONE <br />Dais <br />(0 gyp 0�0 <br />W 0 <br />(�) NAME <br />QUANTITY LOST (GALLONS) <br />4-e eN L <br />UNKNOWN <br />— <br />(2) <br />nal Tc/a14.. �✓� W <br />UNKNOWN <br />w <br />DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL ❑ E:] SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />CM 3 M D TANK TEST TANK REMOVAL ❑ OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />w <br />MI Ml DI DI Yl Yl UNKNOWN <br />❑ REMOVE CONTENTS ❑ <br />REPLACE TANK X CLOSE TANK <br />❑ REPAIR TANK ❑ <br />REPAIR PIPING ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED ? <br />p <br />❑ YES ❑ NO. IF YES, DATE :. MI MI DI D YJ ...Y <br />❑ OTHER '. <br />t <br />SOURCE OF DISCHARGE <br />TANKS ONLYJCAPACITY MATERIAL <br />CAUSE(S) <br />❑ TANK LEAK UNKNOWN <br />GAL. ❑ FIBERGLASS <br />❑ OVERFILL ❑ RUPTURE/FAILURE <br />❑ PIPING LEAK <br />AGE YRS ❑ STEEL <br />❑ CORROSION UNKNOWN <br />❑ OTHER <br />UNKNOWN ❑ OTHER <br />a SPILL ❑ OTHER <br />w w <br />CHECK ONE ONLY <br />a. <br />❑UNDETERMINED SOIL ONLY GROUNDWATER <br />� ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />❑ SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />cc <br />0 <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 />ED SITE (CD) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <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 />A+ <br />HSC 05 (444, <br />