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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES `RORLOCAL-AGENCYUSEONLY <br /> REPORT BEEN FILED 7 <br /> (] ves NO YES NO 1 HEREBY CERTIFYTHATI HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN OU THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE {' CASE % <br /> M16 M J y s SC( G DarE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> (LA ( M d-N V vf� Y6&49t(6 <br /> w REPRESENTING O OWNER/OPERATOR O REGIONALBOARD COMPANY OR AGENCYNAME <br /> o vp <br /> LOCAL AGENCY OTHER SSC E • ' <br /> ADDRESS PA <br /> 6 s REe L CIT s ATE <br /> w NAME / (( n,., / 1Q�p CONTACT PERSON f ,Q - /P/H2ON/�E ZI[P� /g <br /> U3 �k 4 ( 1 Pen �J I-" . �Pu UNKNOWN ( , V "' v \� e ) - 1 s <br /> O a ADDRESS <br /> 36 L '] btb w (lotj 0� I S'�,.J c7o� TA <br /> FACILITY NAME (IF APPLICABLE) s OPERATOR S PHONE <br /> ADDRESS ^ . F b bO oa �� . � �06 Td4 (&vlo 7'r203 <br /> � ) J <br /> STREET CITY cOUNTV ZIP <br /> CROSS STREET <br /> O LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> z i <br /> w REGIONAL 80AR0 PHONE <br /> as <br /> (7) NAME QUANTITY LOST tGALLONS) <br /> Q w T 1 �/ �/ � D� ^,, /� T p <br /> F � 1 U I'e " � F ' 1 f.% �Y � ., /f✓ 1 ��J l O I � G tl?� UNKNOWN <br /> w O> (I2I),, n/� �J 1 <br /> z lLQrO �� (24A% � cqr n� T t CPAP 6 rerUNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> M ZpO TANKTEST TANK REMOVAL OTHER � ( <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> a <br /> M M o y UNKNOWN REMOVE CONTENTS CLOSE TANK & REMOVE O REPAIR PIPING <br /> O(, 1 <br /> p HAS DISCHARGE BEEN STOPPED ? O REPAIR TANK O CLOSE TANK & FILL IN PLACE O CHANGE PROCEDURE <br /> U <br /> YES O NO IFYES, DATE M O MI 0-1 '70 y y REPLACE TANK O OTHER <br /> kil SOURCE OF DISCHARGE CAUSE(S) <br /> j TANK LEAK UNKNOWN O OVERFILL , RUPTURE/FAILURE O SPILL <br /> 00 PIPING LEAK O OTHER u CORROSION O UNKNOWN O OTHER <br /> w CHECK ONE ONLY <br /> O ❑ UNDETERMINED SOIL ONLY GROUNDWATER DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> wZ O NOACTIONTAKEN O PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED E::] POLLUTION CHARACTERIZATION <br /> aF LEAK BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> UN <br /> REMEDIATION PLAN F-] CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPOPR�IAECTION(S) 0 EXCAVATE & DISPOSE (ED) 0 REMOVE FREE PRODUCT (FP) O ENHANCED BIO DEGRADATION (IT) <br /> az <br /> O0 F-1 CAP SITE (CD) 0 EXCAVATE B TREAT (ET) PUMP & TREAT GROUNDWATER (GT) O REPLACE SUPPLY IRS) <br /> w � CONTAINMENT BARRIER (CB) L] NO ACTION REQUIRED INA) TREATMENT AT HOOKUP (HU O VENT SOIL (VS) <br /> ¢ - 1 <br /> VACUUM EXTRACT (VE) OTHER OT) Q er� <br /> i <br /> w <br /> 8 <br /> HSC 0.51b9% <br />