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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OP EMERGENCY SERVICES <br /> REPORT BEEN FILED 7 <br /> C3 Ya C] No Q YES ❑ NO crTEar[}UY�oeurm rw[s rlFCphYLt10R[AL`CCRCi3 ro r <br /> REPORT DATE �iTIDM 5Fi0Y1Mf OM TRf S WOU ME MACE PAGE OFTH15 FCLRA4 <br /> CABS <br /> a` <br /> NAME OF INDIVIDUAL FIL*4 REPORT PHONE SIiNA7URE <br /> ❑ OWNERIOPERATOR ❑ BOAR COMPANY OR AGENCY NAME <br /> J!CJ LOC11L AGENCY ❑ OTHER <br /> m� NAMENUT , [�(I ❑UnArNOWR tj <br /> 304 MIT S&LL^— <br /> OONTACTPE <br /> g AIX>NIpS <br /> FACLITY NAME IF APPLICAKA OPERATOR PHONE <br /> ADDRESS "1460 � 4 M � N � <br /> CPA"STREET <br /> Q <br /> LOCAL AGENCY NAME CONTACT PERSON PHONE <br /> W REGIONAL BOARD PHONE <br /> M G tl Gcl G c ). 6 ._..5-6 a <br /> a fq NAME OUANTETYLOST(GALLON ) <br /> deoCAR-b'0 A/C UNKNOWN <br /> °' ❑ UNKNowN <br /> r- /DATE DISCOVERED �/ HOW DISCOVERED CONTROL C3gPACEµ�� El(/ / Z [ ❑ TANK TEST TANK REMOVAL ❑ OTHER [ <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHAIM(CHECK ALL THAT APPLY) <br /> LINKNOWN ❑REMOVE CONTENTS ❑CAS£TANK a REMOVE ❑REPAIR WOO <br /> HAS DISCHARGE BEEN STOPPED A ❑REPAIR TANK ❑MAW TANK i FLL N PLACE ❑CHANGE PROCEOLM <br /> ❑ YES ❑ NO IF YES.DATE ❑REPLACE TANK ❑OTHER <br /> sauRCE aF DISCi11RKiE CALL NM <br /> ❑ TANK LEAK 54 UNIDO " ❑ ovwu ❑ mAnuiEJFAB.Um ❑ SPILL <br /> ❑ PIPING LEAK ❑ OTHER ❑ coRROIION ❑ uRKNDWN ❑ OTHER <br /> CHECK ONE ONLY <br /> UNDETERMINED ❑ SOL ONLY ❑ GROUNDWATER ❑ ORIKNO WATER-PECK ONLY F WATER W81S HAVE ACYU Y`BEE11 AFFECM <br /> CHECK ONE ONLY <br /> ❑ NO ACTION TAKEN ❑ PROLUINARY SITE ASSESSMENT WORW W SUSMMED Q P=UTTON CHARACTERIZATION <br /> ❑ LEM BEND OOWWAIED ❑ PRELIMINARY SITE AISUSSM NT UNDERWAY ❑ POST CLEANUP MONMMA3 N PROGRESS <br /> ❑ RfEMIEDIATION PLAN ❑ CASE CLOSED(CLEANUP ODM LEVED OR UNNSIDES5AIlM ❑ CLEANUP UNDERWAY <br /> 01+ECc APPROPRINM ACT100M ❑ EXCAVATE i DLfPOSE(EDb ❑ REMOVE FREE PRODUCT[FP[ ❑ O&WICED 510 OEMWATNDN tm 1 <br /> ❑ CAP SITE M ❑ EXCAVATE A TRPiAT LE71 ❑ PUMP B TREAT ONOL I DWATER 1n❑ REPLACE SUPPLY(RS[ <br /> Q CONTAINMENT BARRIER(M ❑ ND ACTION REED fk% ❑ TREATMENT AT HOOKUP(HUt, ❑ VI NT SOL" <br /> ❑ VACUUM EXTRACT OM ❑ OTHER On <br /> �—z7STGSGSSa+ L✓�—/� <br /> nrT a [dl N b r, Tille <br />