Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMER,ENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES NO REPORT BEEN FLED 7 YES NK� 1 HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> �V REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 251807 OF <br /> TH ALTH AND SAFTY CODE <br /> REPORT DATE CASES � ! <br /> u u Y Y SIGNED DAT <br /> NAME OF INDIVIDUAL FLING REPORTt, <br /> PHONE) /�D -�� 7-i,-GA <br /> O REPRESENTING F-1 OWNER/OPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME L/J /�� <br /> ^--� <br /> i1 LOCALAGENCY ❑ OTHER jqN J[1Q ((1„� cpyw LOGGI (IQRR <br /> w <br /> ADDRESS <br /> e STATE 95PLO ZIP <br /> NAME1 CONTACT PERSON / PHONE n <br /> zQ kl r 1�ON ❑ UNKNOWN �C'.( I(/( 'f.IS <br /> R n ADDRESS <br /> N n - I <br /> ¢ • e�REET N Cm L A &TATE ZP <br /> FACLRY NAME(F APPLICABLE) OPERATOR PHONE <br /> Seybold Caas4ra cho•i Co . D ei bo6f (20'�) '?q9-2t52- <br /> ADDRESS <br /> 8,2 S. ,.� Sfoc k N C sa✓ i"?..r 52 o6 <br /> `q CROSS STREET TYPE OF AREA ❑COMMERCIAL NDUSTRIAL❑RURAL TYPE OFSUSINESS [�:] RRETAILFUEL STATION <br /> ❑RESIDENTIAL ❑OTHER ❑ FARM OTHER r(?µ /YA[�jAli Y <br /> LOCALAGENCY AGENCY NAME CONTACTPERSONPHONE <br /> m <br /> .� ora uta LocaLl ea s oaN9t a +J 0 ) 34VO <br /> ly REGKNAL BOARD PHONE <br /> aC PLk) G C7orcjp,> .S (9/b )361-5600 <br /> (1) NAME QUANTITY LOST(a <br /> e Lea UNKNOWN <br /> �riprip? <br /> (23 <br /> - ❑ UNKNOWN <br /> t• //OAATEDISCOVERED Q HOWDISCOVERED ❑ INVENTORVCONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> u V u Su I 0 o VY Y E] TANK TEST Ra"'TANKREMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN MIE-THOO USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> u u D r v FZUNKNOWN LJ REMOVE CONTENTS ❑ REPLACE TANK VOLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? c ❑ REPAIRTANK ❑ REPAIRPPING ❑ CWWGEPROCEDURE <br /> S RZ YES E] No FYES.DATE a Qv 1Y T OTHER Td/.. anal d/S M p,Wtq rrmig&I <br /> w SOURCE OF DISCHARGE ONLY�C ITV MATERIAL CAUSE(S) <br /> ❑ TANK LEAK ne UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFLL ❑ RUPTUREFALURE <br /> ❑ PIPINGLEAK YRS EVSTEEL ❑ CORROSION ge UNKNOWN <br /> ❑ OTHER <br /> Po UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w� CHECK EONLY <br /> UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKNGWATER- (CHECK ONLY F WATERWELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS 0 SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> % ❑ NO ACTION TAKEN ❑ POST CLEANUP MDNITORNG IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAPSITE(CD) ❑ EXCAVATE L DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATioN(IT) <br /> a ❑ CONTAINMENTBARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMPS TREAT GROUNDWATER(GT) ❑ REPLACESLUPPLY(RS) <br /> rr0 TREATMENTATHOOKUP(HU) ❑ NOACTKDN REQUIRED(NA) ❑ OTHER(OT) <br /> TGr-/JIj2/' Sitc QSSPS$NvfN'� W//� � (�tlKhPc� fp d�-f'elyf7Av,� f�iC <br /> ,uGfure a,."/ ex �� crl cd,�f�H,�,✓a�ioN as re�u�rG by flee <br /> oP 4e t7u/a-1Vf- c PAAcirc <br /> KBCOSIAEII <br />