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UNDERGROUND STORAGE TANK UNA EL£A (LE!iAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVK:ES OR,�.00AL AGENCY USE,ONLY <br /> REPORT BEEN FILED 4 jyEREBY,CER FYTiATiHAVE.DISTRIBIIT£DtHiS&ORMAMONACCORDINGTb1HE <br /> El YES NO [:] YESpLSTk&T)CN SHOWN ON THI INSTRUCTION SHEET,ON T}(E Bl1CK FAGS OF PHLS FORM <br /> REPORT DATE CASE s <br /> UAII: ... <br /> NAME OF INDIVIDUAL FILING REPORT PHONE ! SIGN <br /> I a COMPANY OR AGENCY NAME ,h <br /> F REPRES NG ❑ OWNERIOPERATOR ❑ REGIONAL HOARD I <br /> NS <br /> LOCAL AGENCY ❑ OTHER JQ� :L�Ln + <br /> K ADDRAD ESS L <br /> CA- q�za <br /> "•q L. wef/ r` { Gley Il, <br /> k <br /> $TA7>: ZIP <br /> N ME Q/} CONTACT PERSON PHONE <br /> Z G L � S�JC�� ❑ UNKNOWN I r o n c 5ra 8 Z3Z k <br /> a ADDRESS <br /> LLI <br /> Q STATE ZIP 1 <br /> FAC TY NAME(I APPLICABLE) OPERATOR �' 'h PHONE <br /> a <br /> l 1re.�le' a (91o) 3231g?4 <br /> A [ � �� 0L <br /> ADDRESS ' '1 � Y195p?o�] <br /> 0 <br /> W cmr I, courm P <br /> w CROSS STREET <br /> O LOCAL AGENCY AGENCY NAME CONTACTPERSON PHONE <br /> z �.. ui n ��n fin►!pro mct j PLc � f D 3 <br /> w w REGIONAL BOARD ui PHONE <br /> C II) <br /> NAME QUANTITY LOST(GALLONS) <br /> LU C3 <br /> U W }+LJ YY� f1/a ,/`/�Q f�S II, UNKNOWN <br /> z <br /> Q J <br /> r�ii z �S21 ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL }❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w OI Ih� /� h <br /> ut u� V " (y y ❑ TANK TEST TANK REMOVAL p OTHER <br /> a <br /> DATE DISCHARGE BEGAN METHOD USED 70 STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Vi <br /> } UNKNOWN REMOVE CONTENTS 17�[I CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> LU <br /> d HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK I ❑CLOSE TANK 3 FILL IN PLACE ❑CHANGE PROCEDURE <br /> h <br /> T ❑ YESNO IF YES,DATE u� n� r y ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) :I <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL RUPTURE)FAILURE ❑ SPILL <br /> a <br /> a)O PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> W w CHECK ONE ONLY �} <br /> w o_ 1 � <br /> J UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER [71DRINKING WATER -(CHECK ONLY 1F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ZU) ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY j I POST CLEANUP MONITORING IN PROGRESS <br /> U N ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSA11 RY) y CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) ❑ REMOViE FREE PR7UCT(FP) ❑ ENHANCED 1310 DEGRADATION(IT} <br /> J 1$BI&R Fan 00 ALM II <br /> 0 0❑ CAP SITE(CD) ❑ EXCAVATE 3 TREAT(ET) ❑ PUMP 9 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> 4 ❑ CONTAINMENT BARRIER(CS) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(0.0 a <br /> (�n�(� �� 5�r�ct iyi1%s -fuQ tq Ji, n cv, 5f Q <br /> G IVIe the rla.'UVZ`z Qndc4eA+ <br /> on4�cncc%vi aS r e- u L rcf -IkR gppvlo px k. "0 � <br /> ,. ii <br />