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wow <br /> UNDERGROUND <br /> , <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)I CONTAMINATION SITE REPORT 5 <br /> I EMERGENCY :,_ !.HAS STATE OFFICE OF EMERGENCY SERVICES• �Q llpt;¢LAGEIN4YUS�QIVIY .:t��z' x n <br /> ❑ YES NO .. REPORT BEEN PLED 7: E:j YES E] NO ER�B Cr1 Y FfAr AM A�E$ aR :EIY� Y �` ]D Y Y 1 HA1f <br /> L�J � �(oaatri+ 30n�ni. �ctu eua�r rn s�cT�oh dear+ <br /> REPORT DATE <br /> CASES <br /> rw� fEntH aim OWE.'"- <br /> s7 <br /> NAME OF INDIVIDUAL FILING REPORT PHONE nP 9K?dVATCiRE:' 4- <br /> � REPRESENTING <br /> u Q-OWNER/OPERATOR-, REi31CNAL"BOARD COMPANY ORAGENCY NAME I <br /> LOCAL AGENCY OTHER r I { { [� �} <br /> 9 9 .,❑� Aw oc. ul►+ .��.r:_S �t+a'i1�. -VSS'�✓t t1 <br /> A RESS <br /> (,tTRfET - -h �ATf 9szp I <br /> NAME CONTACTPERSON i PHONE <br /> JaN S Oa �.i \ J1 C� ❑ UNKNOWN Z- i}GI�Z 14{� <br /> aADDRESS <br /> Lu <br /> Cc sv.-3 5, A, ..tet c ,�, <br /> CfTV'J` STATE DIP <br /> FACILITY NAME(IF APPLICABLE) A OPERATOR <br /> .-. j1. k� -e... I 'F PHONE <br /> �•n �oe, ..;M aMas ..��. aV l3 1 <br /> ~ ADDRESS <br /> 2-coZIP <br /> H CROSS STREET TYPE OF AREA ❑COMMERCIAL ❑INOUSTRIAL ❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> FeL �- Y 1 4?- ❑RESIDENTIAL OTHER ❑ FARM KOTHER I, <br /> LOCAL AGENCY AGENCY NAM CONTACT PERSON fff <br /> PHONE <br /> w S'.- 500. ��.. {�4L..` �P�,l 7�1 1 J5G t <br /> w REGIONAL BOARD PHONE <br /> l��•.^�ra� Uay�lC fY <br /> 6 r s�b fro <br /> rn (I) NAME Ip o QUANTITY LOST(GALLONS) <br /> Lu <br /> o <br /> a Vo Kew ✓� C .✓l�n.rs UWNOWN <br /> �8 fel <br /> �^��i^-Q-�- �� I UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS } <br /> w i <br /> S.1 YI v ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) ) <br /> ww D Y Y UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> M 1A A II <br /> A HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIR TANK ❑ REPAIR PPING CHANGE PROCEDURE <br /> o YES ❑ NO IF YES,DATE 8 M D D v ❑ OTHER <br /> r <br /> w SOURCE OF DISCHARGE��E TANKS ONLYr-APACITY MATERIAL Ij CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN GAL, ❑ FIBERGLASSII ❑ OVERFILL ❑ RUPTUREIFAILURE <br /> ❑ PIPING LEAK AGE YRS STEEL ii, ❑ CORROSION UNKNOWN k <br /> ❑ <br /> OTHER UNKNOWN OTHER I' <br /> if SPILL ❑ OTHER <br /> CkFCK ONE ONLY <br /> a <br /> chi ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ ORINKNG WATE R - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY I� } <br /> Z(n <br /> cc <br /> Iq SITE INVESTIGATION IN PROGRESS{DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> wII❑ CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> m� ❑ CB <br /> ( ) � EXCAVATE 8 TREAT(E T) PUMP b T <br /> CONTAINMENT BARRIER � TREAT GROUNDWATER(G7) ❑ REPLACE SUPPLY(RS) F <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(O17) TIL <br /> z `S,,.l GPI.,�"aw���a�o�.-, il..a`�Cd dv.i...� T^�Ik ►''C"�'OVp1,_ � Vk0�1��v��vj 1,�,{�ls „ <br /> Esc os u,en <br /> ii �� <br />