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f UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY <br /> REPORT BEEN FILED ) HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE '. <br /> YES No <br /> DYES 0 NO REPO.RTED THIS INFORMATION TO LOCAL OFFIC Aly PURSUANT TQ SECTIGN 251967 OF <br /> REPORT DATE cASEt THE HEALTH.AND.,SAFTYCODE - INV v, �6 -- <br /> Zh <br /> M o Y Y SIBNEp LATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> j 0 REPRESENTING O OWNEWOPERATOR O R IONALBOARD COMPANY OR AGENCY NAME <br /> j ¢O LOCALAGENCY E] OTHER <br /> NAME /� //�q yrLi. <br /> / i(y� CONTACT`TP�ERSON /}f PHONE <br /> w <br /> /v/,o l�/� G (�(l`/VI NS� UNKNOWN JD/�� Kf'9) <br /> RI ADDRESS <br /> T ` z /0v} (/ <br /> CRY / - WFC/ /a • I `i I J <br /> FACILITY NAME (IF APPLICABLE) 6OPERATOR PHONE <br /> ADDRESS I qBE // / 1 u m /fes_/ A <br /> Cm, =JNTV V / p YJ <br /> yCROSS STREET F / TYPE OF AREA OCOMMERCIAL O DUSTRIAL RURAL TYPE OF BUSINESS O pETAILFUEL9TATION <br /> QCT Q RESIDENTIAL O OTHER O FARME::] OTHER <br /> j gy LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> SkAl Z044014 //v <br /> w REGIONALSOARD PHONE <br /> G V 69 �6� <br /> w (I) NAME QUANTITY LOST (GALLONS) <br /> OOUNKNOWN <br /> 15e 007 <br /> O (Z) <br /> H �To 1,* Pi4ie, UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED O INVENTORY CONTROL SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> w1 'a M / D fv �Y TANKTEST ® TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> UNKNOWN O REMOVECONTENTS O REPLACETANK CLOSETANK <br /> M M D 0 Yl Y <br /> l Ix N <br /> o HAS DISCHARGE BEEN STOPPED ? REPAIRTANK REPAIRPIPING O CHANGE PROCEDURE <br /> oO YES O NO IFYES, DATE Ml MI DI al y y OTHER <br /> SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSES) <br /> O TANK LEAK UNKNOWN OOR qAL. O FIBERGLASS OVERFILL O RUPTURE/FAILURE <br />' 0 ❑ PIPING LEAK AGE YRS STEEL CORROSION UNKNOWN <br /> I O OTHER O UNKNOWN O OTHER O SPILL O OTHER <br />,fN1 yy CHECKONEONLY <br /> 13 � UNDETERMINED O SOILONLY O GROUNDWATER O DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> 1 ¢ < O SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) O CLEANUP IN PROGRESSO SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br /> by O NOACTIONTAKEN O POST CLEANUP MONITORING IN PROGRESS O NO FUNDS AVAILABLE TO PROCEED O EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br /> z ❑ CAP SITE (CD) 0 EXCAVATE A DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br /> w4 <br /> s � O CONTAINMENT BARRIER (CB) 0 EXCAVATE & TREAT (ET) O PUMP & TREAT GROUNDWATER (GT) O REPLACE SUPPLY IRS) <br /> O TREATMENT AT HOOKUP (HU) O NO ACTION REQUIRED INA) O OTHER (OT) <br /> A SJf� �95S� S�rn wtGL e Ire" vice 40 hzlhe <br /> e <br /> {y1. e .)G -I— n Go MY tAAAI4/ M <br /> 8 im <br /> NsDo (4Mn <br />