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�Ilmo .4IIIIld 90-a/ <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES �(�(; pH(,Y <br /> ❑ YESREPORT BEEN FLED? ❑YES <br /> ❑ NO #� � � ... <br /> # AR#�'�S t'C�.#�D JIE, P AI F TOI S CTk�t 251M OF <br /> REPORT DATE CASES . � :::. ?'•`•£is#E ''>'"'.?'<»:<:.:::.::•.:::::�,�.?� <br /> w� <br /> V <br /> -Au »> :» <br /> Y <br /> NAME OF INDIVIDUAL FLING REPORT /PHH-ONE /� SIGNATURE <br /> m <br /> cc <br /> REPRESE ❑ OWNERIOPERATOR ❑ REGbNAI BOARD COMPANY OR AGENCY NAME ' <br /> ALAGENCY ❑ OTHER PSS- F. H <br /> e a o0 9 LS�cl�CAW tV Com- add <br /> SrATE <br /> NAME ACTPERSON [ PHONE Q LL/ q J <br /> Q kA L ' Ser v; r 0 - ❑ L arowN �".e rro I �a r Y`�• ! T+�- ! r Q7 <br /> d ADDRESS U <br /> ;05 CRY sfATE ap <br /> FACILITY NAME(F APPLICABLE) ..i--er ro I -r ►'� o� 'yb—�/o 7 <br /> ADDRESS <br /> CROSS STREET TYPE OF AREA COMMERCIAL❑INDUSTRIAL❑RURAL TYPE OF SUSWESS ❑ RETAIL FUEL STATION <br /> 1 ayl, ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCALAGOCY AGENCY NAME CONTACT PERSON PHONE <br /> ILu <br /> f: REGIONAL qQARD PHONE <br /> G Gtr C-L3 ( ) <br /> a� <br /> (1) NAME OUANTITY LOST(GALLONS) <br /> ❑ UNKNOWN <br /> ❑ UNKNOWN <br /> t- DATE DISCOVERED HOW DISCOVERED ❑ IN„,xroRy CONTROL ❑ SUBSURFACE MONITORING NU CDNDmoNs <br /> ao gv DY ❑ TANK TEST ❑ TANK REMOVAL OTHER <br /> M o ===L <br /> DATE DISCHARGE BEGAN METHOD TO STOP DISCHARGE(CHECK ALL THAT Y) <br /> A Ml D1 01 11 �( pWN MOVE CONTENTS ❑ REPLAN TANK CLOSE TANK <br /> HAS BEEN STOPPED? v ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> YES ❑ NO F YES.DATE { M 4A 41 V Y / v ❑ OTHER <br /> SOURCE OF DISCHARGE TANKS ONLYA:APACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN GAL. ❑ FI r7 OVERFILL E7REOFALURE <br /> ❑ <br /> PIPING LEAK AGE YRS STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER UMWONN ❑ OTHER ❑ SPILL a OTHER <br /> W CHECK ONLY <br /> NDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- PECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECT) <br /> CHECK ONE ONLY <br /> F-1 SI NVESTTGI1T10N W PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLE~N PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ) <br /> NO ACTION TAKEN ❑ POST CLEANUP MONITORING N PROGRESS ❑ NO FUNDS AVALABL E TO PROCEED ❑ EVALUATNG CIEA NJP ALTERNATIVES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE a DEPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 610 DEGRADATION(M <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT n ❑ P a TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(NINA) ❑ NO ACTION REOUIRED(NA) C_�L cOn S /4C/L' <br /> 71 <br /> W x � S� l—ides /9.7 r%% - ��i <br />