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9 )- - r, �� l <br /> lo�MERGENCY <br /> UNDERGROUND STORAGE TANK UNAUTHOR ED RELEASE {LEAK)/ CONTAMINATION SITE REPORT <br /> HAS STATE OFFICE OF EMERGENCY;710 <br /> S FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 <br /> YES NO ❑ YES ( BY RT(FY THAT F HAVE STR UTED THIS INFOR TION ACCORDING TO THE <br /> STRIS HOWN ON TH T10N BACK PAGE OF THS FORK <br /> REPOA��T�E CASE f <br /> ul — ul C1 C/q Irl r / raATT'E( Gr <br /> OF'(NDIVIOUt F ING R PORT PH NE ATUAE <br /> ��l In <br /> REPRES INE ❑ OWNERrQPERATOR REGIONAL BOARD CO NY OR AGENCY NAME <br /> aLOCAL AGENCY ❑ OTHER S <br />' cr <br /> ADORES <br /> S /►ILII � r � �IT - Z <br /> ' 3TREE'� CfTV A <br /> 21P <br /> w N CONTACT PERSON �/ �} PHONE �1f <br />' i¢ Vf W '1 �0 Q UNKNOWN ng <br /> ! �� /L <br /> Oq <br /> AD <br /> W 6,)X x <br /> G STATE p <br />' FAC UTY NAME(IF APPLICABLE) OPERATOR PHONE <br /> very 1ADDRES <br /> Iw STREET GITY COUNTY IP <br /> ~ CRO ST EE7 <br /> N <br /> a YDr , ,rte, <br /> I p LO/ A NCY J J AGENCY NAME CONTACT PERSON PHONE <br /> zI� ✓ i ) <br /> w <br /> w U <br /> Ljj z <br /> �10RHONE <br /> �c_n <br /> ) <br /> (1) v f`J NAME OUANTITYLOST(GALL <br /> w d <br /> 4 j UNKNOWN <br /> m O <br /> m R I� <br /> y z <br /> UNKNOWN <br /> z BATE DISCOVERED HOW DISCOVERED VT�VENTORYCONTROL ❑ SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> 2%I K/oI rI r ❑ TANK TESTNK REMOVAL OTHER \� <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHAR (CHEEK ALL THAT APPLY) <br /> UNKNOWN ❑REMOVE CONTENTS E1261OSE TANK A REMOVE ❑REPAIR PIPING <br /> 0 HAS Dt4 ~RGE BEEN STOPPED? J� //� /vyj ❑REPAIR TANK CLOSE TANK L FILL IN PLACE ❑CHANGE PROCEDURE ` <br /> `� YES ❑ NO IF YES DATE �/ [ll� 1 ❑ <br /> o ��vv REPLACE TANK OT1iER y <br /> Y `\1 <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> I G ❑ TANK LEAK UhnVOLN GVEAi=ALL El R RFJFAILURE a SHILL <br /> H ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> rw wa CHECK ONE ONLY <br /> I U ❑ UNDETERMINED SAIL ONLY ❑ GROUNDWATER ❑ DAINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE DNLY <br /> w ❑ NO ACTION TAKEN ❑ PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED Q POLLUTION CHARACTERfT_AnON <br /> I �y ❑ LEAK BEING CONFIRMED ❑ PRFUMINARY SITE ASSESSMENT UNDERWAY ED POST CLEANUP MONITORING W PROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) Q CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE S DISPOSE(ED) Q REMOVE FREE PROOUCT(FP) Q ENHANCED BPO DEGRADATION(IT) <br /> t-q"GACA KR DUALM <br /> ar7oCAP SITE(CDJ ❑ EXCAVATE b TREAT(ET) ❑ PUMP A TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> � <br /> ❑ CONTAINMENT 8ARRSER(GB) ❑ NO ACTION REQUIRED(NAJ ❑ TREATMENT AT HOOKUP(I-IL!) ❑ VENT 301E(VS) <br /> VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> I2� Le. Q�rtA� . " G�rr7�iyx cry L ,-y. G� t` -z- <br /> ��Y 0 <br /> KsccsIm, <br />