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r� <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CO AMINATION SITE REPORT <br /> E❑MEAGENCY HAS STATE OFFICE OF EMERGRJ�Y SERVICESOR 1 OCALAGENGY USE(}NLY <br /> YES NO REPORT BEEN FLED? OVE <br /> YES NO WHEREBY G'kHTIFl�7E{I�T I ASF A pES1E EA GANMEN# EMI�DYE�;AND'MTI oAlk': <br /> TEQ;T#f15.INF.t7HMAT10N t�.,lOClti-GFFIGW :RURSUISNT. Q,SECflGN,251A07:OF: <br /> REPORT DATE CASES THEA <br /> fp <br /> S JNEDJ�,O/' <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATUR <br /> m <br /> w REPRESENTING ❑ QWNER/DPERATOR .❑ REGIONAL BOARD COMPANYOR AGENCY NAME <br /> Eil- ALAGENCY ❑ OTHER <br /> AErss <br /> Q <br /> -267 <br /> Co <br /> STREET I GTl STATE ZIP <br /> NAME �} r' �` CQ TAPE^RSON PHONE <br /> y ��o c � t `^��tC.C��i �'r UNKNOWN ri) vs ��� <br /> z ADDRESS1 T^ Jj �/`]� <br /> a 1 ,53 3 �', �'-! r�Jc I\ �. 0 <br /> sraeEr crrr STATE aP <br /> FACILITY NAME(IF APPLICABLE) OPERATDA PHONE <br /> Q oGK4t7ri fVt&tro - tr a n S; Vk. t,'7tsi . ta0 '?Ll?- 5344 <br /> ADDRESS <br /> S� c ��zJ �J 7s 0 <br /> crry <br /> Fn CROSS STREET`` ] OF AREA COMMERCIAL❑ INDUSTRIAL❑RURAL FTYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> Gp7 W4f CS� �L! ❑RESIDENTIAL (:]OTHER; [7] FARM [2 15THER <br /> L - ,pHs — <br /> , <br /> NCY 14 <br /> NAME <br /> PHONE <br /> z SQm ESO C! ' do A,+ 1 s — F 1 1. b CONTACTP�t50� �T I&Iv �s RD� /1(f-3 <br /> Lu <br /> 4Lu <br /> REGIONAL BOARD fVV/ J PHONE <br /> (1} NAME QUANTITY LOST(GALLONS) <br /> LU <br /> w ie*D I-e Cvm. �C c�-�n�v.� IV4 S�� � ��NDWN <br /> 0 (2) <br /> y- <br /> ❑ UNKNOWN <br /> z <br /> DATE DISCOVERED Q� HOwDISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ 1+EUISANCECONorrKmS <br /> OM uM `�o " o �v v ❑ TMX TEST ANK REMOVAL ��THER ' e <br /> DATE DISCHARGE BEGANMETHOD US D TO STOP DISCHAR (CH K ALL T APPLY) <br /> w M M o o -, v !41 `m SOWN � REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> ` HAS DISC GE BEEN STOPPED 7 1 ' I REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p YES ❑ NO IFYES.DATE V�I 5 Q c� �p �Y (,J Y '� THER r f L n <br /> w SOURCE OF DISCHARGE ' TANKS ONLYA;APACITY MATERIAL CAUSE(S) <br /> g0 TANK LEAK ❑ UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> cc IPINGLEAK AG'ciYRS SEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER Q UNKNOWN ❑ OTHER ❑ SPILL OTHER 13 } <br /> CHECK ONE ONLY <br /> ❑ UNDETERMINED SOILONLY L__I GROUNDWATER 0 DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) jp <br /> CH��<NLY 1J <br /> zN � <br /> INVESTIGATION IN PROGRESS(DEFINING€XIENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cc <br /> U <br /> N ❑ 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 /> 0 z ❑ CAP SITE(CO) ❑ EXCAVATE a DISPOSE(ED) ;❑ REMOVE FREE PRDOUCT(FP) ❑ 'ENHANCED BID DEGRADATKIN(R) <br /> w ❑ CONTAINMENT BARRIER(CS) F—] EXCAVATE 3 TREAT(ET) F—] PUMP 8 TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> Ix <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) OTHER(OT) <br />