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170- u 13 <br /> UNDERG P UND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE DF EMERGE sERVICEs F.DR:LGCALAGENCY USE:ONLY <br /> ❑ YES NO REPORT BEEN FILED? YES ❑ NO 1.HERESY CERTIFY iFlAf E AWA DESIGNATED GQyERNfuIENt EMPLOifEE AND TFIAT E HAVE:; <br /> REPORTED THIS INFORMfATICN TO LOCAL OFFICENS PURSUANT TQ SECTION 251867 OF <br /> REPORTOOATE 7 y CASES THEHEAtTIi CODE <br /> QMI J M ///yj D Y <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> a REPRESS F7OWNERrOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> O <br /> LOCAL AGENCY ❑ OTHER <br /> w <br /> cc ADDRESS f <br /> /kl F, . v'P <br /> srr�EEr ury STATE ZIP <br /> Lq NAME J CONTACTPERSON PHONE 966_0,: <br /> �/ <br /> z �/l!/7 S t!�' ❑ UNKNOWN 0 / ) 7(F(7 Q 1� <br /> S 7 <br /> a ADDRESS <br /> co <br /> cc <br /> � �' foc� •� c 9sav y <br /> Orry STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o 037 <br /> �- ADDRESS <br /> Lu 117 ('0, �CITY NMT'Y y <br /> y CROSS STREET TYPE OF AREA COMMERCIAL INDUSTRIAL RURAL TYPE OF BUSINESS RETAILFUELSTATION <br /> G ❑RESIDENTIAL ❑OTHER FARM ❑ OTHER <br /> LOCALAGENCY AGENCY NAME { OONTACTPERSON PHONE <br /> z �i f<c `�G �C ) fQ� 71�4 <br /> w <br /> w CL C7 <br /> w L, REGIONAL BOARD G' PHONE <br /> a.a. l <br /> NAME QUANTITY LOST(GALLONS) <br /> LU 0LU <br /> UNKNOWN <br /> 1 <br /> (2) <br /> vii- V e, ❑ UNKNOWN <br /> DATE DISCOVERILDHOW DISCOVERED ❑ I NTORY CONTROL ❑ SUBSURFACE MONITORING E] NUISANCE CONDITIONS <br /> w M 3 M 0.1 n (Ypp Y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> 6j <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THATAPPLY). <br /> Lu M M a o r Y UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> 6 H�DIRGEETO ❑ TANK REPAIRIPING ❑ CHIVGE PROCEDURE <br /> Q NO FYE ,DAE MMr r THEIR <br /> w SOURCE OF DISCHARGE TANKS ONLYJCAPACITY MATERIAL CAUSE(S) <br /> co <br /> TANK LEAK UNKNOWN GAL. ❑ FI LASS ❑ OVERFILL �UWNCRWN EJFAILURE <br /> ?APING LEAK AGE YRS' STEEL CORROSION <br /> 9 ❑ OTHER UNKNOWN Q OTHER ❑ SPILL ❑ OTHER <br /> W w CHECK ONE ONLY <br /> V ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONS ONLY ` <br /> 4 ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS E:]'SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> V y a NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> z ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BK)DEGRADATION(IT) r <br /> M ❑ CONTAINMENT BARRIER(CB) - ❑ EXCAVATE S TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> i <br /> TREATMENT ATHOOKUP(HU) ❑ NO ACTION REOUIRED(NA) ❑ OTHER(OTf <br /> �G�rl�c_G. S<� ccss �ss�,+r� wi/1 � `r.[-cpsse�y. '� e�G�G[s:e.•�L., <br /> ui <br /> dr<s <br /> I <br /> KSC 05 luml <br />