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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> i.r.IERc`cNCv Ai STATE OFFICEOF EMERGEN SERVKCES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FLED TI HEREBY CERTIFY THAT I AM A DESIGNATE-0 GOVERNMENT EMPLOYEE AND THAT 1 NAPE <br /> —� YES NO U`IES �-"NO REPORTED THIS INFORMATION TO LOCAL FFCAIS PURSUANT TO SECTION 15,!47 OF <br /> REPORTOATE ( CASE/ THEHEALI,ANOSAFTYCODE <br /> TE <br /> NAME OF INOIVICLAL FLING REPORT PHOHE SIGNATURE <br /> L:A W1 ver (uI 6y- 11� X <br /> C REPRESENTING ❑ OWNEROPERATOR ❑ FEGONAL BOARD COMPANY OR AGENCY NAME <br /> pLOCAL AGENCY OTHER - oc I -11714 G1��s�]/In(i�c <br /> ADDRESS OG� a-X <br /> PH , 8o X =� g S� 7 , f / <br /> j VN <br /> NAME - CONTACTPERSON PHONE <br /> // <br /> Q*P_R5❑�� ed Jnr p��G6,N <br /> .d ADDRESS S 4adl <br /> Em nATc ' � <br /> FACILITY NAME IF APPLICABLE) ICOPERATOR PROW <br /> Td - 111,l STif /o'v E/v'ole"y 5 <br /> ADDRESS <br /> j � �I � S H (it/IT(✓SY/1^ W m .S7U�70AJ �� c/�ZO <br /> y TYPE OF AREA 'X^MI COMMERCIAL❑NOUSTRLL❑RURAL TYPE OF BUSINFSS <br /> .RETALFUELSTATIOHCROSSSTREET MaKYF STW�eAGCY LL ❑OEE = FARM ❑ OTHER <br /> LOCALAGENCY <br /> CONTACT PERSON PHONE <br /> S2- <br /> N ;� Lvcr4 � L r7 -3zz� <br /> y41 REGIONALBCARO PHONE <br /> i G I/2 G✓ GB ( /Ef 3G/sd o <br /> (,) NAME - CUANT. LOST(GALLONS) <br /> ❑ DNQIOWN <br /> LOADJOPAW <br /> i I CATE DISC VE RED /(^ HOW015COVERED ❑ wVENTORY CONTROL ❑ SURSURFICEMONTTORNG ❑ NULSNICECONOTTDHS <br /> LN LGI Ooo [/ r� r ❑ TAN(TEST TAM(REMOVAL ❑ OTHER <br /> 33 DATE DISCHARGE BEGANMETHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> 7 <br /> u ui 0 r v UNf2 ❑ REMOVECOVTFNTS ❑ REPLACE TAM( OSE TAN( <br /> HAS DISCHARGE RUN STOPPED G ❑ TEPAIRTANK ❑ REPAIRPPFO '❑ QANGE PROCEDURE <br /> S YES ❑ NO FYES.DATE Q1 ivy Cd 3o� p. �r ❑ OTHER <br /> SOURCE OF DISCHARGE TANKS�ONLY,CAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN <br /> S-S� DAL. ❑ FIBERDLASS ❑ OVERFILL ❑ RUNMREFALURE <br /> ❑ PIPING LEAK AGE YRS Ix <br /> STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER ® LN(NOYINI ❑ OTHER ❑ SPILL ❑ OTHER <br /> w� CHECK ONE ONLY <br /> u� UNDETERMINED ❑ SOL ONLY ❑ GROUNDWATER ❑ ORIN(NG WATER- ITHECK ONLY 6:WATER WELLS HAVE ACTUALLY BEEN AFFECTM <br /> CHECK CNE ON LY <br /> ii ❑ STTENVESTCATKNNPROGRESS(OEFNNOE)rMWOFPROBLEMH ❑ CLEANUP N PROGRESS❑ SIGNED OFF HQFANIP COMPLETED OR UNNECESSANY) <br /> ami ❑ NOACTONYTAKEN ❑ POSTCLEANIPMONITORNGNPROGRESS ❑ NOFIAOSAVALABLETOPROCEEO ❑ EVALUATIK3CEA14LPALTERNATIVES <br /> CHECK APPROPRIATE ACTIONS)(SEE BALK FOR DXETALS) <br /> ❑ CAP SITE TOO) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PROOIICT IFP) ❑ ENHANCED BO DEGRADATION(m <br /> �� ❑ CONTAPNENTSARRIER(CB) ❑ EXCAVATEATREAT(E-n ❑ PUMP&TREAT GROUN7WATEA(OT) ❑ REPIALEMAN-LY(R6) <br /> ❑ TREATMENT AT HOOKUP THLI ❑ NOACTIONREOUIREOMAJ ❑ OTHER(OT) <br /> /-O k ti S�rcc S e, ct /'�»�v✓ . .�'7/!,6/Z Si <br /> i QSSPSSirtattf WILL L Y �ca//RCS( .fa tle{fitiF.ivr2 t� � `,a{I�ts <br /> 3 A Alper Z K/Lv.f D F GDivTAMii✓�Tiu n/ /I� / a AR.GLC Ady 744� <br /> tL LNG <br /> r�ar.m <br /> EXHIBIT "A" <br /> 00031 <br />