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NNW, . <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)!CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGEp�Y USE ON <br /> YES REPORTBEENFILED? [DYES Ll NO I HEREBY CE. ,T}1AT 1 A.pE TED GOVERNMENT EMPLOYEE 0 THAT 1:HAVE <br /> F—I 'REPORTED SIN :T LOCAL CFFICIALS:PURSUANT TO SECTION&80.1"OF. <br /> REPORTDATE CASES THE HEAL 0 <br /> i M Zdi y Y r SIGNED } ; .: DATE: <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE / <br /> t <br /> > 0.V5� ars (Zol) `f6 0 <br /> m <br /> Lu REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> p LOCALAGENCY OTHER Sar. �OQ �i� Lo�-�� <br /> 4 <br /> ¢ ADDRESS <br /> ��-{��. < � � r <br /> STREET C STATE ZPip <br /> iNAME ----[t CONTACT PERSON PHONE <br /> ��1 Q ���.i ❑ <br /> UN <br /> KN <br /> S <br /> aal ADDRESSLu <br /> (� _ (� q <br /> tiu q I (�. �/V r�A sTREEr e✓r R a t y G F) -1 S <br /> CITY 3 STATE IIp <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> fro« <br /> ADDRESS <br /> Ut T A <br /> O /1(JG I r� ✓vr�d�'1.� �Gdry 1` �. \VAC <br /> STREET J C COUNTY ap <br /> CROSS STREET TYPE OF AREA ❑COMMERCIAL Q INDUSTRIAL RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> -1 r� I ❑RESIDENTIAL ❑OTHER FARM a OTHER <br /> cc77 LOCALAGFNNCY [ AGENCY NAME 1 CONTACTPERSON PHONE <br /> Z5--, JAL any LOca{ �e4 DE$ lvi ct <br /> w { REGIONAL BOARD v PHONE <br /> C�df�vr. po s (�L6)36r-SGoa <br /> {S) NAME QUANTITY LOST(GALLONS) <br /> 0 <br /> UNKNOWN <br /> y Z <br /> ��'}►�`ev.�� dVo CarLjvv� UNKNOWN <br /> z DATE DISCOVERED C HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> C?N ( M 0 3o p y r ❑ TANK TEST ❑ TANK REMOVAL OTHER SOJ b r <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPL <br /> w N M o o y y UNKNOWN REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? REPAIR TANK REPAIR PIPING ❑ CHANGE PROCEDURE <br /> o NT YES ❑ NO IF YES,DATE M1 Ma of of YJ r ❑ OTHER <br /> H SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSES) <br /> TANK LEAK >�[ UNKNOWN 1001Z) GAL, � FIBERGLASS � OVERFILL ❑ RUPTUREiFALURE <br /> PIPING LEAK AGE YRS ❑ STEEL r ) 11 CORROSION UNKNOWN <br /> ❑ OTHER UNKNOWN OTHER SPILL ❑ OTHER <br /> w d CHECK ONE ONLY <br /> U UNDETERMINED SOILONLY E] GROUNDWATER ❑ DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> zy <br /> a ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ¢r <br /> v w NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVALABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 0 4 CAP SITE(CO) a EXCAVATE b DISPOSE(ED} REMOVE FREE PRODUCT(FP) ENHANCED BEO DEGRADATION(IT) <br /> a CONTAINMENT BARREEA(CB) a EXCAVATE 6 TREAT(ET) PUMP 3 TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> KZ C❑ TREATMENT AT HOOKUP(HU) NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> JJl I �Ovih�S Il ��Ger� yiw/ \" C�oSrvQ `lt� U 4C� l��t <br /> Z 1 k ��ti L-- <br /> f2 C�.✓.a C.w+�1"t <br /> Co- .�a`•ti K-• `p h V P-J h e av- q✓a�.r�� wa�G✓ SrI- a:5-5 f i 55 <br /> {�rLes -f- <br /> f`e v i!`e f'o 4� Y-.Z1+rlJ V �f�CG YI or I "Zoyi eK OT <br /> Co�l NSC05(4a1 <br />