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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL^ACBE C, LY <br /> ❑YES 0''� REPORT BEEN OYES NO tREEPORh I I . ..T TI01!TQ S AFF ar�r Ta SEc�roN aslag�oF: <br /> REPORT GATE CASE s TH5 HEALTH' D <br /> �u Sy $ oI $Y b Y SIGNED.......... DA <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> 461- 3 qqv <br /> m <br /> 0 REPRESENTING a OWNERFOPERATOR Q REGIONAL BOARD COMPANY OR AGENCY NAME <br /> �CALAGENCY O OTHER Jai^ oq vi•t Lotr. 4e� I is L <br /> ADDRESS = <br /> ll �� <br /> 67AEET CITY STATE ZIP <br /> � P✓`JdJCC✓S C�DNT" CTPESON ( kPHONE <br /> UNKNOWN <br /> -4 <br /> ADDRESS <br /> it <br /> 4 ¢ TMEEr <br /> �r n `a✓� .Lr;+, e-Jry - 173�(. <br /> C[h' - STATE P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE ; <br /> Cn►ro.��.... (2 3��f - 3 s` <br /> 3 2_ <br /> c ADDRESS <br /> STREET L--GGS t a.: F.- ``G1�w��4• a.�`1 <br /> 4/� <br /> �+ GGIJMIY P <br /> y CROSSSTREET {{, TYPE OF AREA E2-CNAMERCIAL O INDUSTRIAL O RURAL TYPE OF BUSINESS RETAIL FUEL STATKW <br /> RESIDENTIAL O OTHER a FARM O"OTHER <br /> tl LOCALAGENCY AGENCY NAME - CONTACTPERSON .. - PHONE <br /> 2 y� - r w <br /> w Lu REGIONAL BOARD - PSE <br /> q u i NAME OUANTRYLOST(GALLONS) <br /> �Wy p•C'fvo�gv.,... �- d.fo44✓�4•. - :r �IOWN . <br /> UNKNOWN <br /> i DATE DISCOVERED HOWDISCOVERED - 0 INVENTORY CONTROLLu O SUBSURFACE MONITORING - .O NUISANCE CONDITIONS <br /> TANK TEST REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w +� ,a o r r UNRROWN O REMOVECONTENTS O :REPLACETANKS L[�6ETANK <br /> HAS DISCHARGE BEEN STOPPED T . REPAIR TANK ~ REPAIR PIPING O CHANGE PROCEDURE <br /> F3 �S O NO IF YES.DATE d M1 26 �o �r �Y O OTHER _ w; - - <br /> y SOURCE OF DISCHARGE TANKS ONLYCCAPACITY MATERIAL CAUSE(S) <br /> O TANK LEAK UNKNOWN GAL, O FIBERGLASS 0 OVERFILL Q RUPTURESALU'RE <br /> O PIPING LEAK AGE YRS Q STEEL ❑ CORROSION UF�CNOWN <br /> O OTHER Q UNKNOWN O OTHER O SPILL 0 OTHER <br /> W tu CHECK ONE ONLY <br /> chi 0 UNDETERMINED E—SOIL ONLY Q GROUNDWATER Q DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> r CHECK ONE ONLY <br /> Z m <br /> mg Q SITE WVEST)GATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) O CLEANUP iN PROGRESSO SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> Ir <br /> ci y 2 ACTION TAKEN O POST CLEANUP MONITORING IN PROGRESS Q NO FUNDS AVAILABLE TO PROCEED Q EVALUATING CLEANUP ALTERNATNES <br /> CHECK APPROPRIATE ACMN(S)(SEE BACK FOR DETAILS) <br /> 4 z O CAP SITE(CD) O EXCAVATE&DISPOSE(ED) O REMOVE FREE PRODUCT(FP) O ENHANCED Bio DEGRADATION(IT) <br /> n0 <br /> O CONTAINMENT BARRIER(CB) a EXCAVATE&TREAT(ET) O PUMP&TREAT GROUNDWATER(GT) a REPLACE SUPPLY(RS) <br /> O TREATMENTAT HOOKUP(HU) CO NO ACTION REQUIRED(NA) O OTHER(OT) <br /> y _ l <br /> W D� CAhf eL w.i�\�� rie� �V✓-1..1( �1-t� 1/`4�u0 V A l <br /> ��� MSCRSIAA - <br />