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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/WNTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> ❑ YES NO REPORT BEEN FILED v FOR LOCAL AGENCY USE ONLY <br /> REPORT DATE - <br /> �YES = No I HEREBY CERTIFYTHAT t HAVE DISTRIBUTED THIS INFORMATION ACCORDINGTO THE <br /> d /` d �� 6 CASE J DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> {O y <br /> NAME OF INDIVIDUAL FILING REPORT SIGHED <br /> rPHONE SIGNA E DATE <br /> If ft <br /> REPRESENTING ❑ OWNERIOPERA R ❑ REGIDNALBOARO COMPANY OR AGENCY NAM _ <br /> R LOCAL AGENCY ❑ OTHER &4v/1 n I <br /> c A DRESS JRTV <br /> 3o�l F cc7e bar 1 01 BvT� 3W Stoc{r{ cy 45ao/ <br /> 4 REE <br /> w NAME ON srAre <br /> m CCONTA/CT PERSON;., �`1� /J nv <br /> Z¢ '//P—/F O/ l GI/1' ❑ UNKNOWN G/I/V I rc-n i^+iMIC[.1/ j/��jT� PHONE <br /> E a ADDRESS /�•`G'� (�I (p�S�(O///p <br /> 39d GtJ ; flew a ss ct? Scu�e Q0o � Ch <br /> FACILITY NAME(IF APPLICABLE) S ATE <br /> OPERATOR PHONE <br /> S ISAW ea 40-75-610 <br /> U <br /> ADDRESS FiK/T�'�v r <br /> I STREET �/ OGI�1�(/'V �, J • / L-. <br /> vl CROSS STREET <br /> CITY �! <br /> o I LOCAL AGENCY AGENCY NAME <br /> / CONTACTPERSON PHONE <br /> U SAiu�Q Q �. Ce• /v�r / /-G�K J I LA t Tc� tte <br /> D �✓ ^J�( <br /> w w REGK)NAL BOA <br /> PHONE <br /> NAME <br /> w • OUANTITY LOST(GALLONS) <br /> rO (2) UNKNOWN <br /> mz <br /> o _ <br /> m <br /> ❑ UNKNOWN <br /> '- DATE DISCOVERED HOW DISCOVERED <br /> z I I ❑ INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> F M MI q 19,160 9y r ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY)iF <br /> ` <br /> w w D y UNKNOWN ❑REMOVE CONTENTS LOSE TANK&REMOVE ❑REPAIR PIPING <br /> 0 HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK O CLOSE TANK&FILL IN PLACE CHANGE PROCEDURE <br /> O YES ❑ NO IF VES,DATE (Jw p�D y y ❑REPLACE TANK ❑ OTHER <br /> U w CURDS OF DISCHARGE <br /> CAUSE(S) <br /> j a ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑,( RUPTURE/FAILURE ❑ SPILL <br /> O"U ❑ PIPING LEAK ❑ OTHER ❑ CORROSION xI UNKNOWN a OTHER <br /> 57, <br /> w w CHECK ONE ONLY <br /> n <br /> U ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY (>�� <br /> w'A Q NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENTWORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION W <br /> ¢S ❑ LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> �" ❑ <br /> REMEDIATION PLAN a CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ <br /> CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTIONS) <br /> tzf eri ran uT.vsl x EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCEDBIODEGRADATION(IT) <br /> a 0 ❑ CAP SITE ICD) <br /> WF ❑ EXCAVATE&TREAT(9T) ❑ PUMP&TREATGROUNDWAMn(GT)O REPLACESUPPLY(RS) <br /> w a ❑ CONTAINMENT BARRIER(CS) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) J <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> 0 <br /> U <br /> M9C 651�'�w <br />