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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCYAGEN <br /> CY <br /> HAS STATE OFFICE OF <br /> EMEXENCYSE <br /> RVKE8 <br /> ��yy�� g ��y rt�y. '<'''<'- ?'vii;` i!<?Ei }':asEisi'•'�tE�`ii:`:?^:'r.''i5`:?;ii? <br /> t`FMRi. ::'iA1RRF. �I4�6:''`r�?�f%' ���.�:...?:..:.:..•::::::::•::.::::�::::::::::::...:.:;n:.:�::;:::..:::;• <br /> YES NO REPORTSEENFLED? YE8 <br /> REPORT DATE CASES .::::::.:e•.:::... :-:..�-::::::::..,. ..... r::t.::...!..••.:•:r;:..::. ;..;:...:.: <br /> M <br /> Y <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SKGNATU <br /> REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL.BOARD COMPANYOR AGENCY NAME <br /> ¢ ❑ LOCAL AGENCY OTHER S!cop rMcrnodi CtA <br /> ADDRESS ��ll <br /> 301-1 tG�t ocxc� ,St,ili-l-e 16th a xAo lb r oVo- �j4 �(p7b <br /> CITY STATE <br /> NAME CONTACTPERSONPHONE <br /> "1 - E 1evfpu EKG. ❑ Dr inh® c <br /> d ADDRESS <br /> 'P. 4. vx 1! t 601 a.o Tx -75221-®711 <br /> STREET CITY STATEt <br /> FACILITY NAME(IF APPLICABLE) OPERATOR P1iONE <br /> - 22(02 est S. G 111 ( )830-94t7 <br /> ADDRESS <br /> 23100 Wes+ 6-r"+,LZKA.. -Tracy °`" oa���n t537lo <br /> q ciry <br /> CROSSSTREET D t_ TYPE AREA®COMM�y�E)INDUSTRIAL®RUTYPE OF BUSINESS 0 RETAIL FUEL STATION <br /> Joe r Q m Lo 1 ar IOWp 0 ®RESIDFMIAL ®OTHER Q FARM Q OTHER <br /> LOCAL AGENCY AGENCY NAME OONTACTPERSON PHONE <br /> E (11) 468- ` fl <br /> REGIONALBA _ t Valla)? <br /> PHONE <br /> 014) <br /> QUANTITY 5-3 <br /> (T) TITY LOST <br /> ❑ Umm" <br /> DATEDISCOVEREO HOWDNSCOVEREO ® INVENTORY CONTROL ® SUBSURFACE fYOArKGT IWISAN CONDITIONS <br /> D m m I o 3.1 ®r �r ❑ TANK TEST ❑ TANK REMOVAL ® OTHER LitnG �f ®r <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> ml ml IDI al Y1 yl UNKNOWN ❑ REMOVE CON79M ❑ REPLACE TAW ❑ CLOSE TANK <br /> HAS DISCRGE <br /> BEENSTOPPEDZ ❑ REPAIRTANK ® REPAIRPIPING F-1 CHANGE PROCEDURE <br /> FlYES NO IFYES.DATE IA M ol o r Y ❑ OTHER <br /> SOURCE OF OtCHARGE TANKS ONLYACAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK X UNKNOWN L. ®C GAFIBERGLASS O R OVERFILL ❑ RUPTUUAILUFE <br /> ❑ PIPING LEAK AGE S YRS ❑ STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER E] UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> �j CHECK ONE ONLY <br /> �3 UNDETERMINED F] SOIL ONLY ED GROUNDWATER Q DRINKING WATER-(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> NO ACTION TAKEN Q POST CI.EANL)P RoNRTORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED DR EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTDN(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) O EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BD DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CS) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP M O NO ACTION REOUAAED(NA) ❑ OTHER(07) <br /> �n�'G-m►no�cx� . O��cc�v-0-�-�ct d.�..r�,r-,5 p�(�Ar,o� 1�lacs�,^� <br /> rosccsM•p1 <br />