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ATTACHMENT#2 <br /> IX A Documentation for Unauthorized Release <br /> .UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> SIiERGENCYMAS TES OFEMEME11 , 8EMMS :A4 HC 1l5 al :Y��Y� <br /> pQp/��Y�Es }� rio [^�1,�� 7��IATI W(vE <br /> REPORMATE Wc, 81 <br /> CLF WpNIDUAL.FLINQ REPORT P '4 <br /> HES*PKTLlW <br /> S ice? <br /> REPRE-drENTING Q OWNEAK)PERATOR REGMIAL"M OOWMIYORAGENCYNMrz <br /> ¢ LdCALAGE3iCY ❑ OTHER <br /> Amoss S <br /> 37riEfY �Y <br /> >rrwtt <br /> NAME ACT PERSON <br /> �Qf aJIDDfiESS 1 <br /> tu <br /> F:ACA FiY NAME(IF APPLICA8Lk1 � � <br /> OPERATOR KMO <br /> PHONE <br /> ADDRESS � i <br /> I <br /> CFKM <br /> STREEITYPEOFAREA WOOMMG ML❑HDUSTRLIi❑RVRAL TYPEOF8l NESg r <br /> �2 <br /> L 1�w[ ❑�awm ❑�R a RETAL13JEf.9TATgf2 <br /> ❑ FARMOTHER O I <br /> AGENCY AGENCYNAMEA <br /> m CT N PHONE <br /> FC-G BOARD <br /> ZPHONE <br /> Palo[ <br /> tt1 NACRE �1AN1TTYlAST¢3AT10N5) <br /> � �� � 5 11WIQ10YVlt ( <br /> ❑ UNKNOWN <br /> DATEDtSCt3VERED HOW DISCOVERED ❑ trtvETtTDRYODNTFIOL su851UTTFACENIONITOROQ ❑ m ANCEOOWf um <br /> Q 3 o D 25 r ZS r ❑ TAW TEST ❑ TAWREmOV& ❑ OTHER <br /> DATE DISCHARGE BEGAN 141; M USED TO STOP DISCHARGE(C]IECK ALL THAT APPLY) <br /> W u u D D Y VN+SNOYrN ❑ REMOVECObTTt_NTS a REMACETANK ❑ CLOSE TANK <br /> 14AS DISCHARGE SEEN STOPPED 7 ❑ REPAIR TANTO ❑ REPAtR PPtNG ❑ CHANGE PROCEDURE <br /> p ❑ YES ❑ No FYES DATED OTHER <br /> Y Y <br /> SOURCFOFOL,CHARGE TAMCSONLYICAPACITY WATERlALCAUSE(Sy <br /> ❑ TAW tXA1( [ t1NKNONTQ GAL, ❑ FISSMASS ❑ OVERFRx ❑ ftllP7[1FFJFACUF3f <br /> ❑ PSG`EA` AGE YRd ❑ STEM <br /> ❑ OR �[lHECNOyyH <br /> ❑ OTHER tINl(NOwN ❑ OTHER OORRt7^IDN❑ a OTHER'fru OK6CKONEONLY <br /> t3 ❑ UNDETERMINED SOIL ONLY ❑ GRO(NOWATER ❑ OR4✓E m WATER-(CHECK <br /> ONLY F WATER WELLS HAVE ACRTALlY9EEN AFF?C fED} <br /> *$ CHECI(ONE ONLY <br /> ¢ <br /> SITE INVE57A7 !N PROGRESS(DEFINING EXTENT OF PROH(.E7 t] CLE <br /> 1GIOt+1 ~IN PROGRESS 0 5}C7NEDOFF'(( A"CpMP �OR L1NtJECE$9AFM <br /> O7 ❑ NO ACTION IAKEN C] POST CLEANUP MONRORM IN PROGRESS ❑ NO FUNDS AVAlAULt TO PROMM 1=1IALVATTFTG CLEANUP AtTERHATTVE9 <br /> CHECK APPROPRIATE ACTUN(S)($EE SACK FOR CETAI[Sy <br /> CAP SITE(CO) Q EXCAVATE d DISPOSE lED) ElpE1.IOYE FREE PRODUCT(f'p) ❑ ENRANCEMODEGRADAT"(1T) <br /> [� CONTANMENT T3ARRIER(C9) a EXCAVATE d TREAT(ET) PLWP d TREAT GROUTlQWATER(GT) Q REPLACE SUPPLY(FM <br /> TREATUENT AT MOOKUP"- uo ACTK)N REQUIRED(NA) 0 OTTIER(OT) <br /> N�4*.)Tjl BY Itt-f-- r PaoPP-kT-b <br /> E <br />