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i) <br /> � I - (k1 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> �F <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOFi LOCAL"AGENCY USE ONLY <br /> REPORT BEEN FILED 7 ; <br /> ❑ YES NO ❑ YES Q 1HEREBYCERTIFYTHAf!HAVE OlS7RIBU7EDTWISINFORhSATIONACCORDINGTOTWE <br /> DISTRIBUTION SHOWN ON THF INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATEGASE R <br /> 0. uj 2_431 y S1GNE6 GATE <br /> NAME OF INpN{Dt1AL FILING REPORT PHONE SIGNATURE <br /> ibloodI (201)46 -qSr� � <br /> o REPRESENTING ❑ OWNERIOPERATOR F-1REGIONAL80ARD COMPANY ORAGENGY'NAME <br /> p �OCAL AGENCY E::] OTHER <br /> Q ADDRESS . ( R <br /> 3Dt� .V11P 1�QX'�cvQ.v�,U-�-,�h�,r-d �l oa r V� -i L/r• STATE J ZIP [r <br /> 3TREEC CITY <br /> Lu NAMEr�� �-I r CO <br /> r� /PH?O�NEy� <br /> z SOu2A a -G ❑ UNKNOWN i QQ�.`SQ�c.2Q <br /> aa ADDRESS IJ <br /> T�.�- �,� ( PA X153 7 <br /> Lu lfl5 w . ee-fi (o <br /> S7REtT CITY i} STATE iQ <br /> FACILITY NAME(IF APPLICABLE) OPERATOR :� PHONE 1 <br /> z ! <br /> O <br /> a ADDRESS <br /> w STREET Crrr COVNTY 21P <br /> y CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON t PHONE <br /> w JO � 0• .� �/lG{!Ir G ni` <br /> z (op)4-�5-344q <br /> Cu REGIONAL BOARD p tI PHONE <br /> CL <br /> y (1) NAME j+ QUANTITY LOST(GALLONS) <br /> Lu - -ry ,n �] �3i UNKNOWN <br /> m o (2) 1 <br /> y ��J� fi �•�T i UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED it <br /> {� ❑ INVENTORY CONTROL 0 SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS / <br /> w V�� M1 pI 0 �YI r ❑ TANK TEST TANK REMOVAL ❑ OTHER ff� <br /> a DATE DISCHARGE BEGAN �y METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> iyi <br /> UNKNOWN ❑REMOVE CONTENTS OSE TANK A.REMOVE ❑REPAIR PIPING <br /> Lu <br /> HAS DISCHARGE BEEN STOPPED 7 DI YlY ❑REPAIR TANK ❑CLOSE TANK L FILL IN PLACE ❑CHANGE PROCEDURE <br /> U ( 1 1 <br /> 0 ❑YES ❑ NO IF YES,DATE �M 5 Y 1 Y ❑REPLACE TANK OTHER <br /> SOURCE <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> En E-1TANKLEAK ©UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> 0 U ❑ PIPING LEAK E] OTHER ❑ CORROSION jV UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> CL <br /> ❑ <br /> 21�UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> i. <br /> z d NO ACTION TAKEN F-1PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED E:] POLLUTION OHARACTERIZATiON <br /> Er N ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ,i ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATION PLAN F__] CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> 'F <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J t%E RACK ran OETu j I <br /> a z ❑ CAP SITE(CD) ❑ EXCAVATE d TREAT(ET) ❑ PUMP 5 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> uj a El CONTAINMENT BARRIER(CB) ❑ NO ACTION REOUIRED(NA) ❑ TREATMENT AT HOOKUP(HUJ ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑a OTHER(OT) 1 n v <br /> ca <br /> 'F� &J- <br /> 1/lfZ <br /> Q I <br /> FHSC 05 Its% <br />