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t- UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> OYES ONO REPORrBEENFLED? OYES aNO <br /> 3lffY#RFlFY 1AMAifESKiNATEi1GC1iNMEttCM7PLOYE�ANDt3IAT333AVE: <br /> 3 7N6 ECMiA7gTIDN TD <br /> I� REPORTDATE (J(`�7((/ CASES )HFHEAI.2H . t.'DpE PIlfl5l1ANTT4 SEGfIDN?5f88.3'3)F <br /> if w Omi D V V Y <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGNA ' <br /> REPRESENR O OWNEROPERATOR Q REGMALBOARO COMPAI AGENCY NAME {. <br /> pp, AGENCY a OTHER <br /> ADDRESS tY� <br /> DRY 3..TE <br /> NAME CONTACT PERSON <br /> PHONE <br /> y¢ , wwOWN <br /> ADDRESS / 7) 523 <br /> O /✓ " AA-,.4 <br /> FACILITY NAME(F APPLICABLE) OPERATOR <br /> 6ze- f!><2 LTA PHONE) <br /> ADDRESS <br /> CROSS STREET TYPEOFAREA [DCOZERCIAL Q INDUSTRIAL O RURAL PEOFBUSNESS Q RETALFUELSTATO7 <br /> . 0 RESDENTIAL Q OTHER Q FARM Q OTHER <br /> LOCALAGENCY AGENCYNAME CONTACT PERSON PHONE <br /> IAI <br /> BI REGIONAL BOARD PHONE <br /> 111 NAME ^ OW1NTifYIOSi(GN.IDNS) <br /> Y isg5Zly '�/J f! , TIN/OJOYAI <br /> 9 m� (2) - II � UNCNONN <br /> t DATE DISWVERED {OWDL4WVERED O NVENTORYCONTROL ED SUSSURFACEMONTIORNO NUISANCEODIDRANS <br /> MI M D D Y Y TANK TESTTAMC REMOVAL 0 OTHER- <br />- S DATE DISCHARGE BEGANImo// METHOD USED TO STOP DISCHARGE(CHECK ALL TWITAPPLY)-I <br /> M u o o v E? `^`KNOWN - Q REMOVECONiQJTS O REPLACE TANK Q CLOSETANK <br /> HAS DISCHARGE SEEN STOPPED? Lj RREPAIRTANK .�'�iO /RJEPAIRPPNO E3 CHANCE PROCEDURE <br /> 5 Q YES.0 NO IF YES.DATE M D' D Y Y LJ OTHER TJIL � <br /> �r SOURCE OF DISCHARGE TAN KS ONLYCAPACITY MATERIAL CAUSE(S) <br /> 8 Q TANK LEAK M(NONN � GAL Q FIBERGLASS O OVERFILL .LIQ RIRTURFiFAWRE <br /> TEa CORROSION 1MCNOVM <br /> PIPINGLEAK AGE YRS EL <br /> . OTHER Q UNKNOWN OTHER Q SPILL a OTHER <br /> yWE CHECKONEONLY <br /> C} O UNDETERMINED O -SOLONLY "GRWNDWATER Q DRINKING WATER-(CHECK ONLY F WATERWELLS HAVE ACTUALLY13EEN AFFECTED) <br /> t CHECK ONE ONLY Ik <br /> 5m <br /> Ha Q <br /> SITE NVESTKi11TKNNPROGRE33IDFFNNG EX1ENf OF PROBLEM) Q CLEANUP IN PROGRESSQ SgYIEDOFFICLEAp11P COMPIETEDOR UNNECESSARY) <br /> T5A Q NOACTioNTAKEN Q POSTcLE~mONPTORNONPROGRESS Q NOFUNDSAVALABLETOPROCEED 0 EVALUATNOCIF.AMAALTERNATNES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) '( <br /> z O CAP SITE(CO) 0 EXCAVATE&DISPOSE OM REMOVE FREE PRODUCT(FP) 0 ENHANCEDBq DEGRADATDN(m <br /> 21 O CONTAINMENTBARRIER(OB) O EXCAVATE&TREAT(ET) O PUMP&TREATGRWNDWATERL(G1)�-O' REM-40E SUPPLY(AS) <br /> r a TREATMENTAT HOOKUP(Ml) O NOACTIONRECUIRED(NA) OTHER(OT) bE(�/W •I <br /> 3i kms. Sim �9ssasM1,C G�/z/ e, /1aunuv 70 D�� iti •Ui!rcr <br /> .nT�o �TEnro� G�a�vo.Gr�-Tcn C'on T.�f�,u�T� �S 2��i�2c� gS✓ <br /> J/ I <br /> s <br />