Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCYUSE ONLY <br /> ❑ YES ❑ REPORT BEEN FLEDTI HEREBY CERTIGNATED GOVERNMENT EMPLOYEE AND THAT I <br /> ❑YES ❑ NO REPORTED THIS FORMATION AT I AM ATO LOP L OFFICIALS PURSUANT TO SECTION 251807HAVEOFREPORT DATECASEt THE HEALTH AK, <br /> M DM D VY Y SIGNEq DATE. <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGMA <br /> </�/ ( q q5L <br /> w REP ❑ OWNEWOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> S AGENCY ❑ OTHER <br /> ADDRESS �r <br /> /66/ crtr STATE /sem <br /> uJ NAME CONTACT PERSON PHONE <br /> i Ll ❑ UNKNOWN �— II�Q�iL� ) S <br /> y ADDRESS <br /> • Q CITY SrATe N/ P <br /> FACILITY NAME(F APPLICABLE) (-^ OPERATOR PHONE <br /> 66QSthYZ ( ) <br /> tj ADDRESS l. ' <br /> x g-/ a REST � caJ - aQ�CITY <br /> IE CROSS STREET TYPE OF AREA O COM ERCIAL ❑INDUSTRIAL ❑RURAL OPPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSONPHONE <br /> /•v LL�f iL _ l�ric%Z4, <br /> (407) <br /> REGIONAL BOARD PHONE <br /> Sa ( ) <br /> NAME QUANTITY LOST(�G—ALLNONSS)) <br /> (2) <br /> N <br /> ❑ UNKNOWN <br /> DATE DISCOVERED HOWDISCOVERED O INVENTORYCONTROL Q SUBSURFACEMONITORING ❑ NUISANCECONDITIONS <br /> ❑ TANK TEST TANK REMOVAL O OTHER <br /> tiM M D D V r _ <br /> DATE DISCHARGE BEGAN y,.,/ METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M o o v Y Ima=I "'AWN ❑ REMOVECONTENTS [:] REPLACE TANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? REPAIRTANK ❑ REPAIR PPNO�, E:] CHgNOE PROCEDURE <br /> p ❑ YES E::] NO FYES.DATE M M o o r Y u —�R 7��' A��'l`/l <br /> SOURCE OF DISCHARGE TANKS CAPACITY <br /> MATERIAL CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN ��� OUO GAL ❑ FIBERGLASS Q OVERFILL O RLPTUREIFALURE <br /> ❑ PIPWGLEAK AGE�YRS TEEL ❑ CORROSION �NOYM <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w� CHECK ONE ONLY <br /> UNDETERMINED ❑ 901E ONLY GROUNDWATER O DRINKING WATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> f, CHECK ONE ONLY <br /> CLEANUP IN PROGRESS E:] SIGNED OFF(CLEANUP COMPLETEDOR UNNECESSARY) <br /> F-1 SITE WVESTIGATON IN PROGRESS(DEFINNG EXTENT OF PROBLEM) [_ <br /> ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVALABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCTIFP) ❑ ENHANCED Bp DEGRADATION(R) <br /> ❑ CONTAINMENTBARRIER(CS) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY IRS) <br /> leg ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED INA) 'DER(OT) ,� <br /> 3oA sift �seas�r�vT wi/L 1,9MU146W TO vr7E/uii i� r <br /> �iv0 �'%�T� ��uriov�-7� 'C�t ris'�lirr��� A;S 2cz���c� /3S✓ <br /> Ircm(aaA <br />