Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGcENCY HAS STATE OFFICE OF EMERGE SEr7VICt5 FOR LOCAC'AGE3ICYUSE ONLY :> <br /> REPORT aEEN FILED 7 <br /> YES NO YES ❑ NO ;1HEnc3YC'c9T1FY?NATE HAVE O(STHIBUTEJ7Fi1SINFORh1ATlLWACcm mT47HE <br /> AEPORT DATE OLSTRIBUT)ON SHOWN ON THF INSTRUCTION SHE1 ON THE BACK PACE CFTHIS FORhI <br /> 7 -CASE s <br /> " turf: <br /> NAME OF INDIVIDUAL FIUNG REPORT PHONE v f-SIGNATURE <br /> w REPRES NG ❑ OWNER;oPERATOR ❑ AEGiONAL BCARO COMPANY OR AGENCY NAME <br /> LOCAL AGENCY OTHER It <br /> 2 ADDRESS <br /> li <br /> L! Sa J oa u.� } _ S ,do C,h Ate•, <br /> STpEEY CITY IT STATE TIP <br /> NAME 5 CONTACTPERSCN I[ PHONE <br /> Z l) VOW-l' sc,40 .�/ ❑ UNKNOWN <br /> Q a ADDRESS _ I} <br /> i � 3 �Y A Ga I <br /> FACILITY NAME(IF APPLICABLE( OPERATOR crry .j SATE �P <br /> _ �� PHONE <br /> o1.1 . r -SG�ra� r�y'. id <br /> a ADDRESS _ I <br /> 03oY 9ca��d ,e ( C� Tam eu, �r G <br /> ! �n ., 6 <br /> sTFtEEt I° cawrrr P <br /> w CROSS STREET I' <br /> LOCAL AGENCYAGENCY NAME CCNTACTPc�SON <br /> PHONE <br /> 2 y / <br /> z_ J oQ u��y !� o IIl <br /> w w REGIONAL 30ARD <br /> a a PHONE <br /> y {t) NAME .I QUANTITY LOST(GALLONS) <br /> r <br /> Gll7 G UNKNOWN <br /> i ❑ UNKNOWN <br /> = <br /> 0A—jr DISCOVERED HOW DISCOVERED ENT(�ORY CONTROL SUQSURFACE MONITORING ❑ NUISANCE CONOITICNS <br /> 2 1 ,J Duf of %r � r ❑ TANK TE TiaNE W600 eu OTHER <br /> < DATE DISCHARGE 3EGAN ME HCD USED TO SlOP D(SMARGc(CHECK ALL THAT APMn <br /> m <br /> UNKNOWN ❑AEMOVE CONTENTS ❑CLOSE TANK a REMOVE ❑REPAIR PIPING <br /> y <br /> o HAS DISCHARGE 3E;rF STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK a FILL IN PLACE ❑CHANGE PROCEDURE <br /> n ❑ YES ❑ No IF YES.DATEo� of r� r ❑REPTACE TANK ❑ OTHER <br /> O <br /> SOURCE CF DISCHARGE CAUSES) <br /> j ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURFIFALLURE ❑ SPILL <br /> y V PIPING L..AIC OTHER CORROSION UNKNOWN OTHER <br /> �+ <br /> usCHECKO CNLY i <br /> �a.1 UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(C HECK ONLY IF WATER.WELLS HAVE ACTUALLY SEEN AFreCTED) <br /> CHECK ONE ONLY P <br /> ❑ NO ACTION TAKEN ❑ PRELIMINARY srm ASSESSMENTWORKPLAN SUBMITTED ❑ POLLUTION CHARACTERE7ATION ^i <br /> �}7 ❑ LEAK BEING CONFIRMED ❑ PREUMENARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> yl <br /> V ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP gMPC��Es7 OR UNNECESSAR`/) ❑ CLEANUP UNDERWAY [' <br /> I CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PROOUCT(F?) ❑ ENHANCED BIO DEGRADATION(IT) \� <br /> MM 6 a FCR MIALM i <br /> C a ❑ CAP STM c(CO) ❑ E]GCAVATE a TREAT(ETy ❑ PUMP a TREAT GROUNDWATER(GT)❑ AEOLAC^SUPPLY(RS) <br /> I <br /> Lu Q 1 ❑ CONTAINMENT 3ARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT MOCKUP{HIS ❑ VENT SOIL(VSl <br /> C �❑ VACUUM EXTRACT Ne ❑ OTHER(OT) <br /> sSPSS w.`r/ 4�0 owe c ��` cle k.," rl-p <br /> � I ,(pn7 r,-� cc.rTTirni� cr/n GIs � Y Q <br /> 1 d AC I# <br />