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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> ❑VES �--�/ REPORT SEEN FLED? Q YES f ND #t1A�BK IP1l T!#AT#N4>a C # fiAMlT�-AIA�ii#Ai'#F1AU ; <br /> LIQ""' .. 11Cf1,TA, , FAL$Pl1R lillT'I1�.SC.... f131 .7 AF <br /> REPORT DATECASE i <br /> Y ......:i ..:. is <br /> NAME 9F INDIVIDUAL F}MIG REFYRT PHONE S RE <br /> 6C-- <br /> REPilE5W63 OWNERfOPERATOR Q REtGIONAL BOARD COMP OR AGENCY — �P)y LOCAL A094CY Q OTHER < b, �+ ' <br /> CITY ATE <br /> NAME UNKNOWN }-LL `N �s 2 90 <br /> 1y ADDRESS t/b <br /> �C'•`^� sl�'t/ !r-"✓ STATE <br /> FACILITY NAME(F APPLICABLE) r&ZRATOR PHDNE <br /> cUgwee 15 A- I L'?'o7) 7 fI -� r <br /> ADDRESSi 5 J <br /> PT;I-t� <br /> TYPE OF AREA Q WCOMMERCIAL INDUSTRIAL❑RURAL TYPE OF BUSESS Q RETAILLSTATION.Q AESDENTIAL ❑OTHER Q FARM ❑ OTHER <br /> NAME CONTACTPERSON PHONE <br /> REGIONAL BOARD /PHONE <br /> � 1 ) <br /> (1) ( AME <br /> QUANTITY LOST((GALLONS) <br /> El UNKNOWN <br /> DATEDISCOVERED HOWOWC.OVERED ❑ INWWORY CONTROL Q SUBSURFACE MONITORING ❑ NUMANCE CONDITIONS <br /> -17,11 r ❑ TANK TEST EErTANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD <br /> USED TO STOP DW44ARGE(CHECK ALL THAT APPLY) <br /> ml hi al yl Yl �U)NKNOWN [:] REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED 9 ❑ REPAIRYES TANK E] REPAIR PIPING CHANGE PROCEDURE <br /> ❑ N O F YES.DATE r k o pr v E:] OTHER <br /> SOURCE OF DISCHARGE TANS ONLY,CAPACITY MATERIAL CAUSE(S) <br /> E-1TANK LEAK U KNOWN /b O60 — 1 GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREOFALURE <br /> ❑ PPNG LEAK AGE YRS �TE ❑ CORROSION E!4-IN KN0WN <br /> ❑ OTHER Fj�UN(NOWN Q OTHER ❑ SPLL ❑ OTHER <br /> CHECK ONE ONLY <br /> ❑ UNDETERMINED ONLY ❑ GROUNDWATER Q DRINKING WATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> 44qq <br /> CHECKOtp&LY <br /> i SITE INVESTIGATION N PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP N PROGRESS❑ SIGNED OFF(CLEANP COMPLETED OR UNNECESSARY) <br /> a Q NO ACTION TAKEN Q POST CLEANUP MONITORING N PROGRESS Q NO FINDS AVAILABLE TO PROCEED ❑ EVALUATNG CLEANUP ALTERRNATIVES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CO) ❑ EXCAVATE i DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATIONtu <br /> (IT) <br /> ❑ CONTAINMENT SARAIER(CS) ❑ EXCAVATE i TREAT(ET) ❑ PUMP i TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> Q TREATMENT AT HOOKUP OM ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> nacost"n <br />