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C--Lj STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS REPORT BEENF ILEO?EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY <br /> YES p)O REPORT BEEN FILED 7 YES NO I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFCRMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 251807 OF <br /> REPORTDATE ^ CASE;r THE HEAL AND YCODE <br /> M O'(1 M D v Y _sq ♦ D4TE <br /> NAME OF INDIVIDUAL FILING R RT PHONE SIGNAT RE <br /> f�eSC� <br /> p REPRESLOCIAL gGENCV OTHER�PERATOR O REGIONAL BOARD NG COMPANY OR AGENCY NAME <br /> K <br /> ADDRESS <br /> P,o, 9vx aro 9 <br /> NAME STREATE ZIP <br /> � �� . ET 9 <br /> /M. CONTACT PERSON PHONE <br /> m� Cea,«,dt C, WvVt/{ UNKNOWN boo O�-,�fe �- Po9�3glr-a79d <br /> a <br /> <y ADDR 55 <br /> aoX <br /> 5 <br /> /�• <br /> STREET <br /> CCITY SE <br /> FACILITY NAME(IF APPL)CABLE) OPERATOR PHONE <br /> ADDR b • 069 <br /> )33�4�/ � <br /> 2P <br /> 7f6 <br /> (l • /Lb STREET k-0 W <br /> q CROSS STREET TYPE OF AREA OCOMMERCIAL INDUSTRIAL 0 RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> O RESIDENTIAL O OTHER 0 FARM U�rOTHIER <br /> g LOCALAGENCV AGENCY NAME CONTACTPERSON PHONE <br /> w w Sa�n�o� Pu G Nc�. -� D; l�i ls�n caa9J`f� �3 y�6 <br /> w REGIONALSOARD , <br /> PHONE <br /> CRW C ( ) <br /> w (1) AME CUANTRY LOST(GALLONS) <br /> C� NOWN <br /> (a <br /> H <br /> UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED O INVENTORY CONTROL �UBSURFACEMONITORWG O NU`ISA'NCE CONDIT NS <br /> OMa. 'D D r U r TANKTEST 0 TANK REMOVAL OTHER /Yr <br /> DATE DISCHARGE BE ANMETHOD ED TO STOP DISCHARGE(CHECK ALL THAT PLY) <br /> M D D v 11 <br /> UNKNOWN MOVE CONTENTS Q REPLACE TANK CLOSETANK <br /> M <br /> 4 HAS DI ARGE BEEN STOPPED 7 REPAIRTANK REPAIRPIPING CHANGEPROCEDURE <br /> p 7YES O NO IFYES,DATE /M / D �D �r Oy E::] OTHER <br /> u� SOURCE OF DISCHARGE TANKS ONLYiCAPACITY MATERIAL CAUSE(S) <br /> O TANK LEAK UNKNOWN 101 aao GAL. OFI RGLASS O OVERFILL O RUPTURE,FAILURE <br /> O PIPING LEAK AGE YRS STEEL O CORROSION EeUNKNOWN <br /> O OTHER O UNKNOWN O OTHER E::] SPILL O OTHER <br /> CHECK ONE ONLY <br /> 0 UNDETERMINEDSOILONLY O GROUNDWATER O DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ON'_ONLY <br /> c� INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) a CLEANUP IN PROGRESS O SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> Uti NOACTIONTAKEN O POST CLEANUP MONITORING IN PROGRESS D NO FUNDS AVAILABLE TO PROCEED [:] EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> CAPSITE(CD) O EXCAVATE&DLSPOSE(ED) O REMOVE FREE PRODUCT(FP) O ENHANCED BIODEGRADATION(IT) <br /> wCONTAINMENT BARRIER(CB) O EXCAVATE&TREAT(ET) O PUMP&TREAT GROUNDWATER(GT) O REPLACE SUPPLY IRS) <br /> ¢ TREATMENTATHOOKUP(HU) O NO ACTION REQUIRED INA) O OTHER(01) <br /> L ?per/z— <br /> l5z L <br /> Qo��. <br />