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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERG SERVICES 1~p)�L1L>iNCY1)S QN(,Y <br /> REPORT BEEN FN.ED 4 <br /> ❑YES [�NO YE3 ❑ NO 1 H � t Ati�Y tli�lt AM A C� 91c NAt!tl.pOVE�NM Ni MPLrSY t~ANb'f�ls7 t HAVE` <br /> REPORTEb THIS(NFORfi>�ATlOA) CO[AGAL f[G $PUNSUANI TO SGT[gN 251807 CSF <br /> //REPORT DATE (/'/� CASEA <br /> oTH, 5AETY. _; •::;. <br /> . M V RJ" Y _ .......: ....... .......:. ..:;: i .... ii.......ATE .::i �i <br /> NAME OF INDIVIDUAL FLINGREPORT PHONE SIGNATURE <br /> C horbes r/ 34#10 <br /> 0 REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOAR COMPANY OR AGENCY NAME <br /> P/LOCALAGENCY ❑ OTHER ,r aw �r'C! <br /> ,'f G $ /ct's <br /> ADDRESS ����+ <br /> 6Q STRE CITY �7 20 <br /> STATE zp <br /> NAME CONTACTPERSON PHONE <br /> � a ❑ J4�� a� (2v�) ..713 <br /> Q uNKNowN <br /> a ADDRESS <br /> 2 <br /> Ra pi STREE< <XCITY STATE P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR pl ONE <br /> bpiw P_ t T ) <br /> ADDRESS L � �p <br /> J Q STREET "/^f A T/ CR1' A /V COUNTY <br /> CROSS STREET TYPE OF AREA ❑ MERCIAL INDUSTRIAL RURAL TYPE OF BUSINE S <br /> ❑ ❑ RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER ❑ FARM OTHER A.S rYn <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> La Sid &Y11704- 6VA,4 <br /> REGIONAL BOAR PHONE <br /> (i) NAME QUANTTTYLOST(GAL <br /> X UNKNOWN <br /> (2) <br /> ❑ UNKNOWN <br /> DATE DISCOVERED ? �y HOW D13COVERED NTORYCONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> i OM M 2_0 Qy (/Y ❑ TANK TESTfv TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w <br /> MI M o D1 YJ yl UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK TrCLOSETANK <br /> > HAS DISCHARGE BEEN STOPPED T ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p <br /> 0zleYES ❑ NO I=YES,DATE ml ml DI D y y [D OTHER <br /> SOURCE OF DISCHARGE TANKS ONL�Y.y�ACITY MATERIAL CAUSE(S) <br /> 3 F--] TANK LEAK NKNOWN °/ 5 0 GAL, ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURExAI.URE <br /> ❑ PIPING LEAK AGE YRS STEEL ❑ CORROSION 9 UNKNOWN <br /> ❑ OTHER UNKNOWN ® OTHER ❑ SPILL ❑ OTHER <br /> wCHECK ONE ONLY <br /> Lu <br /> v ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> p CHECK OW ONLY <br /> a ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cc <br /> �j H ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTON(S)(SEE BACK FOR DETAILS) <br /> z ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(EDI ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(Ti) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> --r❑^^ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> lQnik / cam/ Sas/ r*m"ms, l`Pd 'f' sri/ cu /dv fu1-flTPr SY�i Q's�PSh7+°n- <br /> � <br /> 61, <br /> NSC OS("n <br />