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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPOR9HHAV��F EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES 11O REPORT BEEN FILED? [::] YES ❑ NO i HEREBY CERTIFY THAT 1 AM A DESIC3lATED V MENT EMPLOYEE AND TREPORTED THIS INFORMATI TO SPURSUANT TO'SECTION <br /> REPORT DATE CASES THE H ANII COO / <br /> MI d o r �r SIGN `'S/ LV_ DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SI <br /> "'t -3wol r" <br /> w REPRESENT G ❑ OWNER/OPERATOR ❑ REGIONAL SO <br /> ARD COMPANY OR AGENCY NAME <br /> p AGENCY ❑ OTHERS/ (� [,//N /L PA SC I+��C•�S <br /> a VV <br /> Lu ADDRESS (6c>( C. a2,r ,,1 <br /> -O+ 2 Q22 RocSTREET CITY STATE - ZIP <br /> NAME CQLITACT PERSON p (PHONE <br /> 2 N El UNKNOWN <br /> a ADDRESS <br /> VSTREET CRY STATE O 21P <br /> FACILITY NAME(IF APPLICA LE) OPERATOR PHONE <br /> -dao <br /> i ADDRESS <br /> W <br /> STREET vim-- crry +✓ COUNTY 23P <br /> y CROSS STREET TYPE OF AREA ❑COMMERCIAL ❑INDUSTRIAL RURAI TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> A?rf- ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> H � <br /> UL -3w � Pw 0 <br /> REGIONAL BOAR PHONE <br /> (�) NAME QUANTITY LOST(GALL ) <br /> m <br /> L>. �. UNKNOWN <br /> y ❑ UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ VENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 0.4'.1 20 DI rly ❑ TANK ST �ANK REMOVAL a OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> CV/UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLCSE TANK <br /> cr W M M D D Y Y <br /> p HAS DI ARGE BEEN STOPPED? �/ /T/ ❑ REPAIR TANK REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p YES a NO IF YES.DATE �II ^01 / of r�VY ❑ OTHER <br /> W SOURCE OF DISCHARGE / TANKS O/N,LrYCCAAP,AACIITY MATERIAL CAUSE(S) <br /> M ❑ TANK LEAK LJf—QyUUNKNOWN ! 000 GAL. 1 �FBERGLASS OVERFILL TUREIFALLIRE <br /> PIPING LEAK AGE YRS ® EL ❑ CORROSION UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> W ICHECK ONE ONLY <br /> ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONS ONLY <br /> 2 ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> y ❑ 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 /> ❑ CAP SITE(CD) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 910 DEGRADATION(IT) <br /> EXCAVATE 6 DISPOSE(ED) � � <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP 8 TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> !O TREATMENT AT HOOKUP(HU)c7 NO ACTION REQUIRED(NA) a OTHER(OT) <br /> luw k te'►j � - Jen /-PSu e-T-alrY/s Cc�..�c7lf��u�"l�dti �I r�htnr s��C Sf�S r� 6- <br /> he Y 1 <br /> w cc;11 • 611 foir ��C ? c N <br /> as �`'(�u/rrc, ,� -,�. aPprd�y-i�' ��r-�/u��,^� a9 pr✓c�Rs <br /> mscm1"n <br />