Laserfiche WebLink
ill J tk3 l <br /> UNDERG UND STORAGE TANK UNAUTHO IZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERV ES FQ _ i'AGENCY jUSE.DNLY <br /> REPORT BEEN FILED a 1 HEaY C RTIFYTWAT 1 HAVE Di l8 DTHIS 1MFORINATIdN ACCORDING TO THEN <br /> ❑ YES NO ❑ YES NO STFlI$U SHOWN ON THE K ACK PAGE 0 GS F <br /> VAI CASE x , <br /> ml IV.N E <br /> Y <br /> L F1LIN REPORT SIGNA <br /> PHONE # <br /> c VI} 4168-0335 <br /> 11 <br /> OWNERIOPERATOR REGIONAL 80ARp COMPA AG NCY.NAMENCY ❑ OTHER Sly <br /> a. <br /> uj ADDR70 <br /> ! f' <br /> - orry ZIP <br /> N1g1•rEI /�"TL�} CONT TPERSON 11 i lPH E J ( <br /> m ��f. V ! 1—W P� r ❑ UNKNOWN 1 l� } C� <br /> F <br /> cAD <br /> D E / 'CrtYC14 STATE cc <br /> 6 G <br /> FIC TY NAME(IF APPLICABLE) OPERATOR ?1 PHONE <br /> _ -GC�2 f C-c <br /> 0 <br /> A RE <br /> a � (%J5'/�f�" W//v r�' [ �/ ��/♦r 1 v " COVMY ZIP <br /> y <br /> 77L <br /> ET <br /> L AL <br /> AG GY I AGENCY NAME CONTACT PERSON +. PHONE <br /> Z w lq! I— <br /> ti <br /> Z GINAL ? PHONE <br /> a Y / [ li <br /> NAME <br /> QUANTITY OST(GALL- 1 <br /> I"o UNKNOWN <br /> zw l <br /> m4 O <br /> n (21 jl <br /> ? !� <br /> y ❑ UNKNOWN <br /> i DATE DISCOVERED kCW DISCOVERED ❑ ENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS 4 <br /> TANK TES TANK REMOVAL OTHER <br /> /J} <br /> W MI MI [ Y Y <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHA E(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑REMOVE CONTENTS EoCLOSE TANK d REMOVE ❑REPAIR PIPING <br /> Lu yo HAS DSS RGE BEEN STOPPED Z ❑REPAIR TANK ❑CLOSE TANK d FILL IN PLACE ❑CHANGE PROCEDURE <br /> w REPLACE TANK' OTHER <br /> YES ❑ NO IF YES,DATE l Y ❑ ❑ <br /> SOURCE OF DISCHARGE CAUSES) 3t <br /> ue <br /> ra E] TANK LEAK UNKNOWN ❑ OVERFILL ❑ PTUREfFAILURE ❑ SPILL <br /> u0i v ❑ PIPING LEAK OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> w a. <br /> 0 ❑ UNDETERMINED VsOILONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w ❑ NO ACTION TAKEN F-1PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ct r ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY �1 ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U y ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> n <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> a z (SEEa. TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> o O ❑ CAP SITEITE(CO)(CEXCAVATE d TREAT(ET) C71PUMP&❑ <br /> w ❑ VENT SOIL(VSy <br /> w CONTAINMENT BARRIER(CB) ❑ NO ACTJON REQUIRED{NA) ❑ TREATMENT AT HOOKUP(HU) ❑ <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) !� <br /> Ah <br /> W �hY1 ? nom' ao <br /> a �-�- <br /> L e xw o5 Mom <br /> h � � li <br />