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UNDERGROUND STORAGE (HNK UNAUTHORIZED RELEASE (LEAK)I:'UNTAMINATION SITE REPORT <br /> SNHAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FLED? -rs/ I HEREBY CERTIFY THAT I AMA DESIGNATED GOVERNMENT EMPLOYEE AND THAT 1 RAVE <br /> NO LL��JJ YES Po REPORTED THIS INFORMATION TO AL OFFICIALS PURSUANT TO SECTION 25150.7 OF <br /> CASES THEN"TH AND SAFTY ., z1„ y.. <br /> - a <br /> SIGN RE <br /> INDIVIDUAL FILING REPoRT._}- PHONEar(es u niI (201 `/G{t 3y5ENTIN6 OWNER'OPERATOR Q REGIONAL BOARD COMPANYORAGENCY NAME OSA UlNLacfAl NeCiLOCALAGENCYO OTHER jrxNJ VS ��ttC _• oze Ho-, VP S R E 1�OC CR STATE ��O I N <br /> CONTACT PERSON PHONE <br /> /K <br /> so I)e- RaoMa E] UNKNOWN (20 1) -b/ <br /> �G <br /> If ADDRESS <br /> 1 -7 <br /> M Q G IJ+ eTReLr ^"I OC k Cm o li ioL STATE 5020 z ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> Ma of vo4) 3 —616/— <br /> ADDRESS <br /> 6/ /ADDRESS <br /> x <br /> Mj N + nl smEET CX T�1 crrr N xry S�O P <br /> fC!ROSSN STREET TYPE OF AREA COMMERCIAL Q INDUSTRIAL Q RURAL PEOFBUSINES9 0 RETAIL FUEL STATION <br /> NJ p j Q RESIDENTIAL Q OTHER I] FARM Q OTHER <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> H (2oq ) 6g-3y�0 <br /> My <br /> ;{( REGKKJALBOAR PHONE <br /> a G lcr i ry oN &17rr <br /> (I) Li NAME WINTRY LOST(GALLONS) <br /> ❑ C (Sd IINe <br /> UNKNOWN <br /> (2) <br /> - UNKNOWN <br /> i DATE DISCOVERED © HOWDISCOVERED O INVENTORY CONTROL SUBSURFACE MONITORING a NUISANCE CONDRIDNS <br /> oM M � D D v v O TAMC TEST TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> > UNKNOWN ❑ REMOVECONTENTS O REPLACETANK CLOSE TANK <br /> Maj Y M D D V Y <br /> M HAS DISCHARGE BEEN STOPPED? E] REPAIRTANK E::] REPAIRPIPIN3 CHANGE PROCEDURE <br /> S YES 0 NO FYES.DATE (11M DI I D Yl r ❑ OTHER <br /> u� SOURCEOFDISCHARGE TANKS ONLYICAPACITY MATERIAL CAUSE(S) <br /> g O TANKLEAK UNKNOWN 100! S GAL. O FIBERGLASS O OVERFILL a RUPTURErFAAURE <br /> ❑a O PIPINGLEAK AGE [[kN YRS 0 STEEL O CORROSON 0 UNKNOWN <br /> OTHER 0 UNKNOWN O OTHER O SPILL 0 OTHER <br /> Wq W CHECKONE ONLY <br /> g� UNDETERMINED SOIL ONLY 0 GROUNDWATERO RF DRINKING WATER ONLYWATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> Qi ❑ SITENVESTIGATKUN IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> NOACTKNTAKEN O POST CLEANUP MONITORING IN PROGRESS NO FUNDS AVAIL-ABLE TO PROCEED O EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> j O CAPSITE(CD) O EXCAVATE 6 DISPOSE(ED) O REMOVE FREE PRODUCT(FP) O ENHANCED SIO DEGRADATION(IT) <br /> RRIER(CB) O EXCAVATES TREAT(ET) O PUMPb TREAT GROUNDWATER roT) O REPLACE SUPPLY(RS) <br /> 2Y O CONTAINMENTBA <br /> O TREATMENT AT HOOKUP PAS O NO ACTION REQUIRED INA) O OTHER(OT) <br /> F �e9c+T/`C'� ten /-rc;u/Q-lp^cj -/f`T9u;rPynd.'is Fur�lTtr s/� �lssPsb?rti.� r-s <br /> (E 4uMPc/ fo �PrinlNG f/rc n�c+�ur�l p ex fa f o{ <br /> el (cf�cl' t'C✓+Alit .. <br /> / 16ca6IAeT1 <br />