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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGEWY U E ONLY <br /> ❑ VE <br /> YES REPORT BEEN FILED7 ❑YES ❑ NO REPORTED THI IN MATIOO I N JO LOCAL OFFICIALS A DESIGNATED PURSUANT URSUANT TO SECTION 251807MENT EMPLOYEE AND THAT I AOF <br /> RrrEfPORTDATE a `/ CASE* THE HEALTH S Y /�/it- <br /> Vw SM J 6 y a y SIGNED / CATE <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGNATURE <br /> > DQV\O ^r`S (25t) y68-3yvo <br /> o REPRESENTING F-1OWNEPoOPERATOR E] REGIONALBOARD COMPANY OR AGENCY NAME <br /> 0 <br /> LOCAL AGENCY ❑ OTHER ,p.\ V\� �T\+ Loa.ol T'T Q.�I'Y�-. U1 ✓i c� <br /> a <br /> A RESS <br /> cA- 9szP I <br /> clry <br /> NAME - CONTACTPERSOTN- PHONE <br /> ■� \o e�4 Tov. -F'. . ❑ UNKNOWN Ra Yo..✓.A.e,. (21)4$2-3260 <br /> aNJ <br /> A <br /> <y ADDRESS 1 ` <br /> SJ� GA �LSzmz- <br /> IJ � WAT6 ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> To w. ah r • R u ta.✓whe✓- ( 2AR) 4S2 -326 o <br /> ADDRESS <br /> CITY ZIP <br /> `3 �p�0 �l , NV••\�C✓ *meet <br /> CROSS STREET TYPE OF AREA XOOMMERCIAL Q INDUSTRIAL Q RURAL TYPE OF BUSINESS O RETAIL FUEL STATION <br /> oqk ❑RESIDENTIAL OTHER ❑ FARM OTHER <br /> LOCALAGENCY AGE'N'CY NAME CONTACTPERSON PHONE <br /> Sim sm\ So Loc. ( Hecl'YL. c'4-W,- (tai) HG$-3Y2d <br /> 9 PHONE <br /> REGIONAL BOARD <br /> 1REGIONAL <br /> IOU NAME QUANTITY LOST(GALLONS) <br /> w <br /> �� e-�✓�(.� ,.,ti. � cavo ce.r�.,.s ,® <br /> UNKNOWN <br /> �i- t✓I�e`^� UNKNOWN <br /> t OCTEDISOOVERED HOWDISCOVERED O INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCECONDITIMS <br /> I uI I wI c.->o �- oI &.v 'f-'l ❑ TANKTEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN 1� METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w w o o v v CS? UNKNOWN UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK Y CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIR TANK ❑ REPAIR PING ❑ CHANGE PROCEDURE <br /> -p I� YES ❑ NO IFYES,DATE 1 w I w Op 6 o k y +y ❑ OTHER <br /> SOURCEOF DISCHARGE TANKS ONYICAPACTY MATERIAL CAUSE(S) <br /> ❑ � ( Goo ( opo ,� FIBERGLASS <br /> TANK LEAK UNKNOWN t ❑ ❑ OVERFILL ❑ RUPTUREffAILURE <br /> ❑ PIPINGLEAK AGE YRS ❑ STEEL ❑ CORROSION Y UNKNOWN <br /> ❑ OTHER UNKNOWN �wl OTHER G40tN ❑ SPILL ❑ OTHER <br /> w� CHECKONEONLY <br /> ❑ UNDETERMINED SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F- CHECKONEONLY <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> tiH ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ <br /> NO FUNDS AVALABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCEDSIODEGRADATIONVT) <br /> Z ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> �M ❑C TREATMENT AT HOOKUP(HUI ` ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> 1- ./O\ \ C.�M�c�.Ni1.. .�TOH K.>�C� Va.'�M �GM� ✓'�-\+•\OV4( <br /> 1 <br /> nSC Ps la2n <br />