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�AFile 1-.DD. <br /> ti 3} �..,y:. ;,5 LUSTIS J JL.ArL.�p <br /> .n'a c e .cfi` chez $� Ate' #. �i•.y1 �ti� <br /> ,x •�:• ��i he t}3z,:-�:r„k.:.5. � � ��•:-..r,.. .� Y.?:r' ,�< � .: 5�.Y`:.a; <br /> Leakyinyg Under round Fuel Tank Data Collection Checklist Local 2212 <br /> x .}. ,5,,i+a,,q0 ,, i•. ,.5$s';at ? ., 'S s.•. °':.? •j (.� <br /> },�� p <br /> R1l�/QC.B <br /> i <br /> SITE: - <br /> ADDRESS: <br /> CITY: <br /> nn► COUNTY: S -Suwcwki REG. BOARD No: <br /> REVIEWED BY: X DATE: <br /> (Name) (Agency) JiSfal <br /> i. RELEASE INFORMATION (FROM TECHNICAL REPORTS OR OTHER FILE DOCUMENTS) <br /> a) Check[X]type of product(s)whish leaked: ® Gasoline ❑ Diesel <br /> I <br /> ❑ ether <br /> b) Was source of leak identified? C2E--) NO <br /> If YES, check[X]source location(s): 0 Tank ❑ Piping ❑ Overfill <br /> i <br /> ❑ Other <br /> c) Was rate of release estimated? YES <br /> If YES,specify rate: <br /> d) Was masstvolume of release estimated? YES ®O <br /> If YES, specify masstvoiume (note unit of measurement): <br /> e) Was tank removed? NO <br /> If YES, specify: 52 C-,AfUST- -F55 <br /> COMMENTS- <br /> 111. SITE INVESTIGATION INFORMATION (FROM REPORTS OR OTHER FILE DOCUMENTS) <br /> a) Was"free product" reported? YES <br /> If YES, check[X] location(s)where free product was noted: ❑ Excavation ❑ Soil Sample <br /> ❑ Monitoring Well <br /> If MONITORING WELL, specify maximum thickness reported (note unit of measurement): <br /> b) Was a soil vapor survey conducted? YES <br /> c) Was an aquifer test(e.g., pumping or slug test) performed? YESb <br /> d) Number of monitoring wells installed at the site IS <br /> I <br /> e) Number of soil (or"Hydropunch") borings NOT completed as wells_ <br /> COMMENTS: <br /> I <br /> I <br />