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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALpCENCY USE YES LY{J Np REPORT BEEN FILED YEg NO EHERE8Y CERTIFYTHATI AM A:DESIGN 6 COVERWdENE EMPLOYEE AND TMT I HAVE: <br /> REPORT DATE CpgE• O ❑ �R <br /> REP �)SN�MATICN TO LOCA).tF (ALS PURSUANT TO SECTION 2SIaU OF <br /> LVDE <br /> �MI I N 04 a fY ®Y <br /> NAME OF INDIVIOUAL FILING REPORT PHONE X2/�g' SIGN TORE TE <br /> J - <br /> 0 AEPRESENNO WNERIOPERATOR REGIONALBOARO COMPANYORAGENCY NAME <br /> pqo: LOCAL AGENCY BOTHERta <br /> ADDRESS JtI <br /> STREETdiY +SPATE M m Of <br /> m NAME ` CONTACTPERSON PHONE K.2/O$ <br /> UNKNOWN fQlrr, 6204')9#3- <br /> m <br /> i ADDRESS <br /> EEf CRY STATE <br /> FACILITY NAME RF APPLICABLE) OPERATOR PHDNE <br /> ADDRESS <br /> �J11 STREET LAV O <br /> F. CROSS STREET TYPE AREA O COMMERCIAL Q INDUSTRIAL O RURAL T'PEOFSUSINESS a RETAIL FUEL STATION <br /> O RESE)ENTIAL Q OTHER O FARM 02�OTHEq / <br /> g LOCALAGENCY 'AGENCY NAME ODNTACTPERSON PHONE <br /> Qo ) `t6F3 `fao <br /> d!y REGIONAL BODDAR 4da 10' , 1 /� PHONE <br /> 0 <br /> ()I NAME QUANTITY LOST(GALLONS) <br /> ( &6UNCNOWN <br /> (T <br /> UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> /.10.1 I-1 o Ov v T TEST TANKREMOVAL OTHER <br /> DATE DISCHARGE BEGAN �—�( METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w u u o o v v to UNKNOWN �REMOVECONTENTS Q REPLACETANK � CLOSETANK <br /> Q <br /> HAS DI RGE BEEN STOPPED 7 1 '7 REPAIRTANK Ej REPAIRPDWG � CHANGEPROCEDURE <br /> p �S Q NO IFYES.DATE u1 L o / o v v OTHER <br /> H SOURCE OF DISCHARGE TANKS ONLY,CAPACITY MATERIAL CAUSES) <br /> �TANKLEAK O UNKNOWN AJOO GAL Q FIBERGLASS O OVERFILL E:] RUPTUREFALURE <br /> ED PIPING LEAK AGE YRS Fo/sTEEL O CORROSION dUNKNOWN <br /> Q OTHER Q UNKNOWN O OTHER O SPILL =] OTHER <br /> w w CHECKO NLY <br /> a <br /> O� UNDETERMINED SOILONLY O GROUNDWATER E] DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ON:ONLY <br /> z� <br /> ei = SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) = CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> �H E�] NOACTIONTAKEN a POST CLEANUP MONITORING IN PROGRESS NO FUNDS AVALABLE TQPROCEED O EVALUAT)NGCLEANLP ALTERNATIVES <br /> CHECK APPROPRIATE ACTON(S)(SEE BACK FOR DETAILS) <br /> S CAP SITE(CO) Q EXCAVATE a DISPOSE(ED) Q REMOVE FREE PRODUCT(FP) O ENHANCED BIO DEGRADATION(m <br /> CONTAINMENT 13ARRIER(08) a EXCAVATE&TREAT(ET) PUMP&TRFATGROUNDWATI:R GT) REPLACESUPPLY(RS) <br /> TREATMENTQ OO ER ` I'LL <br /> 6 <br /> /i2C / �7� <br /> 8 ✓42 cy �t 4U' <br /> /I -y-/ ^�, NSCOSI� <br />