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UNDERGROUND STORAGE TANK UNAUTHORIZED, RELEASE (LEAK) CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />OR <br />YES REPORTBEENF� ED? YES NO <br />IRs RT1F#..CaOk�iE�IEN... E....— A�14 f�7Af,) HA1 <br />TiarSFtcl PURSUANT TWSECT. <br />N.. <br />REPORT DATE=CASE#E <br />a'INED'. ..::... >:..::.:.;::i TE ..::........... <br />M`M D <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE <br />m�dA <br />Of a C.'k:' <br />(2 <br />) 'qf t- -s g q o <br />a <br />REPRESENTING Q ,OWNER/OPERATOR 0 REGIONAL BOARD <br />COMPANY OR AGENCY NAME <br />m AL <br />AGENCY E OTHER <br />�e <br />saw u+4 'Lata I I-� I{L+ oS'FrT� <br />s <br />ADDRESS <br />gg PP <br />1(00 L zi <br />' <br />STREET <br />CRY STATE ZIP <br />NAME ' <br />CONTACT PERSON: PHONE <br />'�Yr <br />❑ tHNKNQwN <br />F{liS (z-,g)a <br />4a <br />ADDRESSLu <br />(� <br />414-6 A <br />STREET <br />CRY STATE ZIP <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />2 T -: wnwww.iC:io.*,+S <br />r <br />�^ t (PHONE <br />Jd C(�.1 S ICoQ} 3c�r3��S <br />ADDRESS <br />., <br />(pq <br />-+ <br />"�- g '�yl ( <br />V !t® �! vN'w:'�r I�+G! <br />�oC®8 w�.- a.FW Y Z.y <br />STREET <br />-. CRY .COUZIP <br />CROSS STREET TYPE OF AREA MMERCIAL 0 INDUSTRIAL a RURAL TYPE OF BUSINESS a RETAIL FUEL STATION <br />Lo,,,-, „„ L, Q RESIDENTIAL Q OTHER Q FARM , R <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON PHONE <br />wg <br />w w <br />REGIONALBOARD <br />PHONE <br />E , <br />y <br />(1) NAME <br />QUANTITYLOST (GALLONS) <br />�Tvolevw <br />�vo car �,awg NowN <br />vX <br />(2) <br />UNKNOWN <br />DATE DISCOVERED IOW DISCOVERED INVENTORY CONTROL ®SUBSURFACE MONITORING � NUISANCE CONDITIONS <br />w <br />oi? . ( M '-. j D1 YJ 4-v TANK TEST ANK REMOVAL ® OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />UNKNOWN <br />F-] REMOVECONTENTS F REPLACE TANK ETANK <br />p <br />MI MI DI D1 r , Y <br />HAS DISCHARGE BEENSTO <br />F-� REPAIR TANK F-1REPAIR PP�IG F-1CHANGEPROCEDURE <br />4� <br />❑�YES, DATE t 2-3 �' <br />[' M M D <br />� OTHER <br />D Y Y <br />SOURCE OF DISCHARGE TANKS ONLY/CAPACITY <br />MATERIAL ` CAUSE(S) <br />TANK LEAKUNKNOWN GAL. <br />FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br />2 <br />F-] . PIPING LEAK - AGE: - YRS <br />- - E] STEEL,'. F"-1 CORROSION NOWN <br />9 <br />E::] OTHER E:] UNKNOWN <br />Q OTHER ❑ SPILL a OTHER <br />W w <br />CHECK ONE ONLY <br />v FE <br />[::] UNDETERMINED SOIL ONLY a GROUNDWATER [-] DRINKING WATER • (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONE ONLY <br />Z <br />a <br />F-] SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS a SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />v rn <br />❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS <br />❑ NO FUNDS AVAILABLE M PROCEED Q EVALUATING CLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />CAP SITE (CD) F --j EXCAVATE & DISPOSE (ED) <br />F--] REMOVE FREE PRODUCT (FP) E:] ENHANCED BIO DEGRADATION (IT) <br />WF7 <br />CONTAINMENT BARRIER (CB) a EXCAVATE & TREAT (ET) <br />F-1 PUMP & TREAT GROUNDWATER (GT) 0 REPLACE SUPPLY (RS) <br />TREATMENT AT HOOKUP (HU) NO ACTION REQUIRED (NA) <br />OTHER (OT) <br />NSC05(4187) <br />