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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)!CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES ...... <br /> 'FOR LOCALAGE <br /> iISE;ONLY <br /> REPORT BEEN FILED 7 ❑ ❑ <br /> YES NO YES NO AC <br /> f HEREBY CERTIFYTHAT( HAVE DISTRIBUTED THES INFORMATION CORDING TOTHE <br /> ❑ ❑ <br /> QISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE SACK PAGE OF THIS FORM <br /> REPORT DATE CASE I <br /> vM l M V v SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE ' <br /> q�?-3 qqj <br /> REPRESENT4AGOWNUIOPERATOR ❑ REGIONAL BDARD COMPANY OR AGENCY NAME <br /> TL <br /> LOCAL AGENCY E::] OTHER .�0-k 0- 11//'� co�° e�( vt <br /> g e ,l cJercy f C' <br /> Q ADDRESS'303 r 4 P l oor c,� <br /> S� <br /> STREET GTI STATE ZIP ) <br /> Lu NAME <br /> � ff S CONTACT PERSON PHONE,. <br /> z �t1lrlmerc� �►(c 24 ❑ UNKNOWN } t <br /> rr <br /> as a ADDRESS <br /> Q p a <br /> STREET CRY STATE IP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE JI <br /> UADDRESS <br /> W 1 I A�TREPlAn c-, S�� -�dq irk 9 533 <br /> CITY COUA ZIP <br /> CROSS STREET <br /> LOCAL AGENCY AGENCY N E CONTACT PERSON <br /> Z 1 PHONE <br /> nJOo! �nrt Irdnmea (meq ) <br /> w REGIONALBOA D PHONE <br /> CL a �ra l/a ( ( } <br /> m NAME QUANTITY LOST(GALLONS) <br /> w O <br /> Lu 01C SID � ( rt -� <br /> C b UNKNOWN <br /> m z (2) I <br /> D— <br /> ❑ UNKNOWN <br /> r DATE DISCOVERED HOW DISCOVERED <br /> z ❑ INVENTORY CONTROL SUBSURFACE MONITORING NUIS CE C�OCNDITIONS <br /> w (h/ SIpJ/�7� <br /> w v M1 -I ` D b v Y Y ❑ TANK TEST ❑ TANK REMOVAL OTHER it (( 4 <br /> I- <br /> a DATE DISCHARGE BEGAN METHOD USED TO TOP DISCHARGE(CHECK ALL THAT APPLY) <br /> cc <br /> UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK R REMOVE - ❑REPAIR PIPING <br /> w M M b Y Y <br /> p HAS DISCHARGE BEEN STOPPED Z ❑REPAIR TANK ❑CLOSE TANK d FILL IN PLACE [::]CHANGE PR�EDUR-E! <br /> a ❑ YES [:] NO IF YES,DATE M b b Y Y EJ REPLACE TANK OTHER Sere v16 0-5 c �'5r <br /> �-q L, SOURCE OF DISCHARGE CAUSE(S) <br /> U) <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> U ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> y ww CHECK ONE ONLY <br /> O ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY j <br /> i <br /> z 0 ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w <br /> cc y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> (WE eat FM rrtvus� <br /> El 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION((T) <br /> a <br /> 0 0 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMPS TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY{RS} <br /> Lu <br /> Lu¢ ❑ CONTAINMENT BARRIER(CB) ElNO ACTON REQUIRED(NA) E:] TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> 2 <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> z S c �e W I (l .D e 1 (a CCA 1 n LO C�.. d t1 ems'S ` t1`f FF D_q!'a m u n. <br /> 'It re-C-# [ vll U es 'lGe'�e a o�c! f P�n�ec `T r�•J Co"m c <br /> • <br /> HSC 05(MO)) <br /> } <br />