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UNDERGROUND•STORAGETTANK,UNAUTHORIZED RELEASE(LEAK)[CONTAMINATION SITE'REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERYKS Fpq IOCAI AGE C LY <br />" ' ` N FI,ED <br /> _REPORT BEEY c. -' <br /> c. <br /> YESVES [ ; No (HPER:.. f r ... `A ups t i..... JME :��1PLU"YEE n�tDYHA 3 HAYS,` j <br /> REPORTER 7HI !N TSN 7A t]FFICIALS PU...... T TO S CTiQN,25180.7 OF <br /> REPORT DATE <br /> n <br /> SM t 8 $ fr ;slorlEon�TE.: �I <br /> NAMES OF INDIVIDUAL FILING REPORT PHONE la SIGNATURE <br /> qqo <br /> REPRESENTING OWNER(OPERATOR' R€G10W1L80ARD �MPANYORAGENCY NAME ,: t <br /> �CALAGENCY-❑'iOTHER .?'_ F-; ' ,,,,iF �oq r.iti L�ocstil. `���._�-+'� DiS�✓iGl <br /> w ADDRESS <br /> Itoo t �' �'ti�e�`}�� - P gip. Qoj�:' ?Oo a•\ ���: �. 'y. ,C/� " _ �-z� I , <br /> CITY �.; - STATE' '� ZIP <br /> AME r :.; CONTACTPERSON PHONE' . <br /> �2a'f) 33 <br /> Ncr;c:- � UNKNowN � 3�i — rZ <br /> a <br /> � <br /> ADDRESS <br /> Y <br /> 5TREf'T ..- crry STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> qekL Cif <br /> j� ADDRESS �'f-.- r;,F • - � ./ �i r. .- `Gf,u.�S� t.� Q S'Lc(� - <br />' •. gz .E Tam S? L�aac1ap <br /> SET' uTr <br /> TYPE OF BUSINESS ' <br /> y CROSS STREET r. ^ �. - Y_ _ TYPEOFAREA �.�MMERCIAL O INDUSTRIAL Q RURAL { _ K�a RETAIL FUEL STAT <br /> SA.G�-�pk.. : C ? ". Q RESIDENT{AL.Q OTHER f Q FARM DIRER,` <br /> p LOCALAGE^NNCY 'I 1 AGENCY NAME 1 CONTACTPERSON 1 PHONE <br /> z� �. Vnei .i:�+ �Gc�� R - kvi, DSS 1Jic� Lq�✓rte �T..��g E2�� �G�-j�(Z$ <br /> Lu S� PHONE <br /> LREGIONAL BOARD <br /> () NAME t OU/WITTYLOST(G�ALLON� <br /> �o �-c-�Yole.r-r- cT a�e�q✓�.� ' <br /> (Z) ❑ uww. <br /> y <br /> HOW DISCOVERED ❑ INVENTORY CONTROL Q SUBSURFACE I+IDNITORING NUISANCE��rc <br /> DATE DISCOVERED 1 <br />+� <br /> u� M ° v �Y ED TANK TEST Eq REMOVAL ❑ OTTER <br /> METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> DATE DISCHARGE REGAIN KNOWN ❑ REMOVE CONTENTS ❑ _-REPLACE TANK L "TANK <br /> u n p r r REPAIR TANK <br /> uI <br /> ❑ REPAIR PIPING O CHANGE P <br /> FIA5 DISCHARGE BEEN STOPPED 7 E-1 ' <br /> 2 4 P - ❑ OTHER <br /> o �. ❑ NO P YES.DATE p u SMI o o r Y CAUSE(S) <br /> TANKS ONLYCAPACITY MATERIAL ❑OVERFLL RUPTUREJF <br /> LI SOURCE OF OISCHARGE GAL. ❑ FIBERGLASS ❑ <br /> ! 77 ❑ TANK LEAK ❑uNKNOWN STEEL <br /> PiPINGLEAK ❑ CORROCORROSIONN i <br /> �.�r^YRS ❑ ❑ SPILL Q OTHER <br /> {j ❑ ElO7HER.��.•�_ <br /> x ❑ <br /> ❑ OTHER UNKNOWN <br /> j CHECKONEONLY DRINKING WATER- (CHECK ONLY IFWATERWELLS HAVE ACTUALLY BEEN A 1 <br /> w rve� a GROUNDWATER Q <br /> u ❑ UNDETERMINED u SOIL ONLY <br /> CHECK ONE ONLY CLEANUP iN PROGRESS Q SIGNED OFF(CLEANUP COMPLETED OR UNNE i <br /> ❑ SITE INVESTIGATai IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ FUNDS AVAILABLE TO PROCEED Q EVALUATING CLEANUP ALTEP <br /> r POST CLEANUP MONTTORNG IN PROGRESS ❑ f <br /> w ACTION TAKEN Q Q.ENHANCED BX)DEGRA13 <br /> CHECK APPROPRIATE ACTION(SI(SEE BACK FOR DETAILS) REMOVE FREE PROOUCT(M PLY(RS) <br /> SUP <br /> ❑ CAP SITE{GD) Q EXCAVATE 6 DISPOSE(ED) ❑ pUTAP✓!TREAT GROUNDWATER(GT) Q REPLACE <br /> 8 ❑ CONTAINMENT BARRIER(CB) Cl �(CAVATE 6 TREAT(ETj ❑ <br /> ❑ NO ACTION REOLIIRED(NA) ❑`OTHER(OT) <br /> ❑ TREATMENT AT HOOKUP(HU) r <br /> , �•, is <br /> 4 r ` <br /> -ha I� �t �qa+1� ✓K'4VdV� • e +�- <br /> y�.__. <br />