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Aa rl <br /> 1 <br /> OUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> HAS STATE OFFICE OF EMERGENCY SERVICES S FGFi f:OCAi:'AGENCY[USS ONLY <br /> NO REPORT BEEN FILED 7 ❑ YES ❑ No 1 HEREBY CEFiT[FYTHA7 i HAVE.DiSTRIBU E1 D 7NI5INFOFIMATION ACCORDENG TO THE <br /> t]I UTfON S OWN ON T INSTRUCTION EET ON THE SACK PAGE THIS F M <br /> PO RT ...... <br /> DATE CASE i <br /> M / MI t/ 4 o ;SIGNED :::',. z.. DATE.is <br /> :.:. <br /> E OF INDIVIDUAL FILI G REPORT PHONE SIGNATURE <br /> o <br /> o REPRESENTING OWNERlOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> Q ❑ LOCAL AGENCY ❑ OTHER <br /> ¢ ADDRESS37 <br /> STREET er y ��"' STAT Zf P r' <br /> J NAME CONTACT PERSON PHONE <br /> a bh� UNKNOWN¢ l &---Q t <br /> f <br /> a ADDRESS <br /> wCc <br /> 0. ice '-'" �I I •STREET l�G..`.L�+.-� CT' 4 " C ko-,� STATIL..'C jC0 <br /> 71 <br /> FACILITY NAME(IF APPLICABLE) DPERATOR PHONE <br /> PA 0 o o b f -f ( ? <br /> ADDRES GrrY 5teC/ <br /> 0 <br /> w STREET COUIYT"Y r ~ 5 s 2, <br /> y CROSS STREET <br /> O <br /> LOCAI,AgENCY AGENCY NAME CONTACTPERSON PHONE <br /> zy <br /> �L=u,.E r <br /> Z REGION ARD '' ll PHONE <br /> (1) N ME OUANTITY LOST(GALLONS) I <br /> w O <br /> J .� i 1 (j�/ UNKNOWN <br /> m z (2) <br /> UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING NUISANC6C6 DITIONS <br /> w MI �MI o 0 YI E::] .TANK TEST ❑ TANK REMOVAL OTHE l-&r—',_, 1111 <br /> ¢m ATE DISCHARGE BEGAN METHOD USED 70 STOP DIVRGE(CHECK ALL THAT APPLY) I <br /> trUNKNOWN ❑REMOVE CONTENTSCLOSE TANK&REMOVE REPAIR PIPING I <br /> w <br /> M M 0 Y Y <br /> 0 <br /> HAS DISCHARGE BEEN STOPPED T ❑REPAIR TANK Q CLOSE TANK S FILL IN PLACE CHANGE PROCEDURE <br /> U <br /> f1J/j � <br /> I� I YES ❑ NO IF YES,DATE to / NI �'0 7 O Y y Y ❑REPLACE TANK OTHER <br /> d <br /> SOURCE OF DISCHARGE CAUSE(S) , <br /> w <br /> L) ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> ti" ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> CL <br /> d ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w ❑ NO ACTION TAKEN PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED [:j POLLUTION CHARACTERIZATION <br /> cr LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY' ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTIONS) EXCAVATE E DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ENHANCED HIO DEGRADATION(IT) <br /> J ISM SOCK FOR UETALM <br /> F3 0 F7CAP SITE(CD) ❑„EXCAVATE S TREAT(ET) ❑ PUMP d TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) VENT SOIL(V5) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> L! S I 5o* j-4<cA4,c, LC5-7 <br /> Lu <br /> HSG CL 1�1 <br />