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UNOERGE30UND STORAGE Ti iK.UNAUTHOFUZED-RELEASE.(LE rK) CONZpMtNpTJON WE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY U$E ONLY, <br /> AEPORT BEEN FLED? <br /> El YES NO ❑YE3 -Na # EREBIt C>wF(i1FY Ti(!)T 1 A1�a4 t�ESK�@ATgp GQV it ET EMPLOYEE ANIITNAT!:)SAVE <br /> REPORT DATECASE* <br /> OR F#�IS�EFE iI+IATIF '3 £�C�1' F�W3,I lA1�T1 180T <br /> _ CASE s ANO s <br /> :.. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATWRE <br /> REPRESS- ❑;pyy RrOPERATOR•. ❑ AEGKjNAL BOAFO �PANY OR AGENCYNAME <br /> � "J� -- <br /> p �AL AGENCY;❑ OTHER .. ... r t r ' <br /> a <br /> ADDRESS <br /> arY = Zp <br /> NAME F. CONTACT PERSON I PHONE l <br /> ❑ UNIaVDWN I y 7 f �/ / ' Z <br /> a AESS` r r- �. <br /> STREET. 'p �. WAIT � - ` <br /> F NA6SE(F/1PPLICA$LEI OPERATOR <br /> 'CR0333TFEE7 .s - k �.r. .r. TYPE OF AREA��COMMEACIA! ❑NDL13TR4L O RURAL TYEOFBUSNESS ❑ RETAIL FUEL STATION <br /> J > ❑RESIDENTIAL ❑OTHER ❑ FARM © OTHER <br />+ LOCAIAGENCY t ACQ4CYNAME OONTACTPERSON _ I PHON$ <br /> Q REGIONALBOAIa'..- <br /> 0�—`� PHOW <br /> �.. (�J}A\'�__. I - /NAME I 1D"' • L06T OALLO" <br /> S -A <br /> vo <br /> DATEDIEGOVEREp�,:} DI9COVER$D ❑ NVENTI7RYCONTADL' i RFACEW IITWiNL�.. ❑ NUISANCE •NDIT•,OONDITO gllil <br /> i1 I T a TANK TEST ., �ANK REMOVAL' <br /> DATE DISCHARGE BEGAN <br /> METHOD USED TO STOP D13C}IARQE(CNECi(AI 1 THAT AP?L <br /> Lu u p p Y; UNKNONN ❑'. REMOVECONTENIITS ❑:RE'PLACE,TANK � CLOSE TANK <br /> HAS[!)$CHARGE BEEN STOPPED 7 c i'c -. {�.�. ¢ A ❑ REPAiR_TAPIK';.• I� } REPAIR PPSIG: .. -.❑ CHANGE PROCEpLRE <br /> SFYES.DATE .&u_ F f D O r' Y ❑:0T1A7. <br /> I SOURCE OF DISCHARGE TANKS CLW--Y.CAP%CHY ••,9TE .�' - k + r -"-"�' __ <br /> ❑ <br /> TANK" ❑ UNKNOWN �� ' fiAL ❑ FIBER(iLA39 k Cr"EWLL ❑ PUPTURESAEURE <br /> ❑ PIPNGLEAK € Ar <br /> ❑ STEEL: .❑ CORROSION UNKNOWN <br /> ❑ OTHER 'UNKNOWN ❑ OTHER .. ❑ SPILL OTHER <br /> CHECK ONE ONLY ❑ <br /> ._s^":. .. ^^ rte _ '' - :: � -:_ �r � Y x ::; �,�:` �° i..�:;:c .. t_.. •,' - . <br /> �IJHDETEAw►NED ❑' SOTL ONLY_ ❑ GROUNDWATER ❑ DRNKNO WATER- (CIH6CK ONLY F WATER WELLS HJAYE ACTUALLY BEEN AFFECTED} <br /> CHECK ONE ONLY• :. ,P. .' <br /> ❑ SITE INVESTIGATION N PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CL EANUP N PROGRESS!❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ❑ NO ACTIONTAKEN ❑ POST CLEANUP MONTTORNG N PROGRESS '❑ NO FUNDS AVAILABLE TO PROCEED VALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTIDN(S)(SEE BACK FOR DETAILS) - I� <br /> ❑ CAP STiE(CD) 'k'.: - Y ❑ EXCAVATE 8 DISPOSE(ED) ❑ AE)IOVE FREE PRODUCT9(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> CONTAINMENT BARRIER I 1 <br /> ( ) © EXCAVATE 6 TREAT(ETJ PUMP 8 TREAT GROUNDWATER <br /> � ❑.' ` (GT) ❑ REPLACE SUPPLY(R3) <br /> ❑ T REATMENTAT HOOKUP(►AJ) ❑ NO ACTION REOUIRED(NA) ❑'OTHER(OT) <br /> NSC m ISI <br />- - HI <br />