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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY• <br /> ❑ YES Cj!(NO REPORT BEEN FILED? ❑YES (HEREBY CERTIFY THAT 1 AMA DESrMTED GOVERNMENT EMPLOYEEAND THAT i HAVE <br /> Lt^1 REFORIE THIS WFORMATION T6 LOCAL CFFICNALS PDRSUANT TO SECTM 251801 OF <br /> RE(PORT DATE �I v//� CASEi THE ANO SAFTY <br /> r M 2M 2_I B / TI OY $Kf- TE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE � j-�j/ SIGNATURE w <br /> > B! SO 1 (-7- <br /> a <br /> � J <br /> m COMPANY ORAGENCYNAME <br /> w REPRESENTING OWNEROPERATOR ❑ REGIONALSOARD <br /> O ❑ LOCAL AGENCY ❑ OTHER <br /> OrL_ c0 <br /> w <br /> ¢ ADDRESS <br /> /390 /GLOK! HESS Jam- � 9� CO�C�Q�j G.4 9�iZ� <br /> STPEET CRY STATE ZN <br /> NAAMM+EECONTACTPERSON PHONE <br /> ®/ � �r UNKNOWN ^�( /`7 L/, <br /> R ADDRESS AS �� CO _/l^r•> }, �Q %4/JZT <br /> �, 0 80x 4023 jGC" Kf� <br /> '7STREET CRY STATES/yJ� <br /> FACILITYNAME(IF APPLICABLE) <br /> PHONE <br /> Z OPERATOR / <br /> Gw4iL`r `- 7VH/w�f//'r�L�a �r KCl�L1X,LJ�C <br /> < ADDRESS <br /> % �-.atlh�. r/ <br /> Y'O/3 / D,4�1�/G r�✓ � �TOGLc <br /> srREEr <br /> CRY <br /> couxrr P <br /> F CROSS STREET TYPE OF AREA ❑ a TYPEOFBUSINESS <br /> F -y�O_, C� ,(� COMMERCIAL WOUSTRIAL RURAL RETAIL FUEL STATION <br /> )47O)E'l E -� fA'S'W r O RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCALAGENNY AGENCY NAME CONTACTPERSON PHONE <br /> 9.zw <br /> w M REGIONAL BOARD (PHONE <br /> NAME OUANTTTY LOST(GALLONS) <br /> w el�lCE�� CssO L 1.�CE2G2^� <br /> U w UNKNOWN <br /> ❑ UNKNOWN <br /> Z DATE DISCOVERED �j Z14OWDISCOVERED INVENTORY CONTROL ❑ SU13SURFACEMONITORNG E::] NUISANCE CONDITIONS <br /> w OM ZM �or/ o �TjY ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> l rn/ <br /> UNKNOWN d <br /> M M O 0 T I YREMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> // R <br /> p HASDISCHARGE�YES ❑ENO t YES,DATE �' 2M12o�/R��v�r ❑ OTHER TANK ❑ REPAIR PIPWG ❑ CHANGE PROCEDURE <br /> w SOURCE OF DISCHARGE TANKS ONLYICAPACITY MATERIAL CAUSE(S) <br /> 0?�TANKLEAK ❑ UNKNOWN JOsGbO GAL ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREFARURE <br /> ¢ <br /> ❑ PIPINGLEAKl,.LLD AGE YRS STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER / ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> ww CHECK ONE ONLY <br /> ❑ UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKWG WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKONEONLY <br /> Zy <br /> SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ QEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ¢a <br /> V m ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVALABLE TO PROCEED AjeEVALUATING-CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> C5 Z ❑ CAP SITE(CO) ❑ E%CAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATON(IT) <br /> wr PUMP B TREAT GROUNDWATER(GT) REPLACE SUPPLY IRS) <br /> 1� ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE6 TREAT(ET) ❑ ❑ <br /> ❑ ,W„��,� �/ <br /> TREATMENTATHOOKUP(HU) ❑ NO ACTION REIX11RE0(NA) ❑ OTHER(On lAL <br /> 4r amZ666r <br /> ,4G[_ 7-o4,(//c-5 AIS1b L1Ao6t�s TD Woo <br /> F/EcK�rcAss Yr(`f/TT/.cl�i P �rEn <br /> E�S St.�b� ✓.A2/o,lS <br /> ,g�i�,c6ClE5 BY irtJ54iOT IV, 44ESsoc. AA16 4,,F-Cx/S <br />