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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT I <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> FOR.LOCAI AGENCY USE ONLY <br /> REPORT BEEN FILED 7 ' <br /> ❑ YES NO ❑ YES ❑ no i HEREeI,CERTIFYTHA71 )ERNE RISTRIBUTED THIS INF.bRMATION ACCOHD(NG TO THE <br /> dist I8UTIONSHOWNONTHEINSTRU TIONSHEETONTHEBACKPAGEOFTHISFORM <br /> REPORT DATE CASE S <br /> call MI �d �� r SGNoaTE;:::: <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> REPRESENTING ❑ OWNER/OPERATOR ❑ REGSQ AL BOARD COMPANY OR AGENCY NAME 1 l , ,� <br /> aLOCAL AGENCY E::] OTHER Iii 1 <br /> ADDRESS ���/J'/�1� by 11 ��// <br /> C/ �" STATE �ZIP <br /> STREET .,s I <br /> w NAME !wz �� CONTACTPERSON PHONE <br /> UNKNOWN DeZlg ', <br /> f5 ] � r <br /> ADDRESS <br /> a �,wirfit•�-5 lZl!lam �m 9 <br /> Lu <br /> PJ 5� <br /> Lu <br /> sraTE Iv <br /> FACILITY N pF AAPLICABLE) OPERATOR PHONE <br /> LD <br /> e ADDRESS <br /> 3TRt�f Nc ,rrr T37 <br /> � GOUtlTY Zk1� <br /> y CROSS STREET <br /> vt-, <br /> LOCAL AGENCY AGENCY NAME - CONTACT PERSON �PHO�NEJ (� <br /> z <br /> w U ! <br /> Lu� REGiONALSOARD PHONE <br /> w <br /> (1) - NAME QUANTITY LOST(GALLONS) <br /> U O <br /> Z>❑ UNKNOWN <br /> H <br /> Q J <br /> m z (z) <br /> Lo ' ❑ UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ INVF�IIOp� TA'RN�� SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w it l Dol 1 '12, <br /> Z ❑ TANK TEST TANK REMOVA THER <br /> a <br /> m DATE DISCHARGE BEGAN METHOD USED TO STO DISCHARGE(CHECK ALL THAT APPLY) <br /> ¢ u o <br /> 11 yl ❑ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING y <br /> 0 <br /> HAS DISCHARGE SEEN STOPPED? REPAIR TANK ❑CLOSE TANK&FILL IN-PLACE 0 CHANGE PROCEDURE <br /> U <br /> E]—YES ❑ NO 1FY£S,DATE <br /> 0 MI u� n d Y, r ❑REPLACE TANK E::] OTHER— <br /> SOURCE OF DISCHARGE CAUSE(S) G <br /> a ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> v ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w Lu CHECK ONE ONLY <br /> v ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> =1 <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING 1N PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) F-1ENHANCED BIO DEGRADATION(IT) <br /> J IBFGX EOR OETAf.S1 <br /> a Z <br /> 0 0 ;SEECAP SITE(CO) ❑ EXCAVATE&TREAT(ET) 0 PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> 0 <br /> wLu <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(01) <br /> cn L6 U � � �- lYeA!l 44 las rias <br /> z <br /> tS$C d5 ia'�1 <br /> } <br />