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0014 0111% <br /> UNDERGROUND STORAGE TN JK UNAUTHORIZED RELEASE(LEAK)/C NTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENGY.USE ONLY <br /> REPORT BEEN FLED 2F:#IEREBX CERTIFY THAT I ANE A:oESXtATED GOYEpNMENP EMPLOYE AND THAT f HAVE <br /> ❑YES NO [:]YES ❑ No REPORTED THIS INFORMATION TO)ACAL:flFFICFALS MMu To ecTrox s25W OF <br /> REPORT DATE ry �J CASES THE H TH AND SAFTY CODE f}j off, Nf / <br /> QM QM oC yv / r SIGN ,> MTE <br /> NAME OF INDIIVIDUALFLING REPORT PH�O}NEq SIGNATURE <br /> co <br /> (/VI <br /> >. a /✓ L GC <br /> 0 REPRESENTING g OWNER/OPERATOR REGIONAL BOARD COMPANY OR AGENCY NAME <br /> a0 [—] LOCAL AGENCY ❑ OTHER <br /> Q ADDRESS <br /> STREET CRY STATE DP <br /> NAME C / / CONTACTPERSON PHONE <br /> G/ e,, r/X ❑ UNKNOWN <br /> ( ) <br /> a <br /> ADDRESS4 <br /> ��,/ e A/ <br /> STREET CRY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS -I'�P J ?� 7�v Ir.A/ �/L1a�C(i�✓ QV�GtI <br /> 3 73 o fYf a.� r c� <br /> STREET cm courrrr zip <br /> yCROSS STREET n TYPE OF AREA COMMERCIAL 0 INDUSTRIAL Q RURAL TYPE OF BUSINESS 0 RETAIL FUEL STATION <br /> �f��j' �J,C /"% ❑RESIDENTIAL 0 OTHER ❑ FARM CE�OTHER T,PGC)- 7FA;o.?,c <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> y ( ) <br /> W Sj <br /> w'�) REGIONAL BOARD PHONE <br /> % (1) NAME QUANTITY LOST(GALLONS) <br /> W C3 <br /> �- S a 4-,C UNKNOWN <br /> ❑ UNKNOWN <br /> DATE DISCOVERED _ /f HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> U /M / /o d v p v ®-TANKTEST ❑ TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> W M M DI 01 Yl vUNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN Q ®AYES ❑ NO STOPPED?IF YDATE M M o D v v LJ OTHER TANK Fe�❑ REPAIR P7,-I❑ CHANGE PROCEDURE <br /> u� SOURCE OF DISCHARGE TANKS ONLYUCAPACITY MATERIAL CAUSE(S) <br /> ��iGGG <br /> D ❑ TANK LEAK ❑ UNKNOWN '5'SO GAL ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREfALURE <br /> c� ®'PtPING LEAK AGE _YRS STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w W CHECK ONE ONLY <br /> VIL <br /> ❑ UNDETERMINED 02losoILONLY R GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK EONLY <br /> zq <br /> SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESSSIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> H ❑ NO ACTION TAKEN 0 POST CLEANUP MONTORING IN PROGRESS 0 ND 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) ❑ ENHANCED 810 DEGRADATION(R) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ <br /> TREATMENT AT HOOKUP( U)H ❑ NO ACTION REOUIREO(NA) ❑ OTHER(OT) <br /> F I (o ro urta wcc4e.l- Mon{f o r-i nuje-a i'n 5l PEW <br /> Fur� <br /> -�- Q5s mss r►�,+n cwt e ,� n <br /> SEP 2 <br /> ENVIROMENTAL HEALTH <br /> FERMIT/SERVICE <br />