Laserfiche WebLink
It i <br /> UNDERGROUND STORAGEAT NK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES 'FON LOCALAGENCY USE ONLY <br /> REPORT BEEN FILED 7 <br /> ❑ YES � NO ❑ YES NO 1 HEREBY CERTIFYTHAT(HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE WSTRUCTION SHEET ON THE BACK PAGE OF TIS FORAAA��� <br /> REPORT DATE CASES f2�(�� <br /> O N � 9 Y SIGNED I DATE I <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> m <br /> L.orti bvt%)CAA) (wl) 16T033:iL-I 6m&ct <. <br /> w REPRESENTING ❑ OWNELOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME ` �\ <br /> S5d LOCALAGENCY ❑ OTHER <br /> ADDRESS <br /> 30LI (c• wGhe►r $?tackTaiv CA- qS�Z <br /> Sf1�ET Gm SLATE <br /> av <br /> w NAME CONTACTPERSON PHONE <br /> =z 0'F ESCA�N ❑ UNKNOWN DOI.I Sri orb4nl (xs()49 Md ) <br /> H as <br /> ADDRESS <br /> p /syn ;L0 � O <br /> ¢ 1 / STREET CRY �� �� BTATE C • Y � <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o WO- 5o�drkdClAK � a—��( KO NtaK of c ) <br /> a ADDRESS <br /> w l 30S S REST 5 E5rALoA Ave GSCAt,v,,o ( fA QS32p <br /> y CROSS STREET <br /> A%&W [2-0 <br /> O LOCAL AGENCY qa NAME CONTACT PERSON r`a HONE ��� ��� <br /> z $�� Pwbl�z {}e�l )� h <br /> Q REGIONAL BOARD�� �� I•AYH_Ltbl MI PHONE <br /> a(t,16li-6 Zss`3t3z <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> w J / , / <br /> w A5ow A)g UNKNOWN <br /> ;5 <br /> mZ <br /> J- <br /> ❑ UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL E::] SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> o Y1 dyl ❑ TANK TEST �g TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Ml D1 Yl Y fIUNKNOWN ❑REMOVE CONTENTS fOQ CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED? Tc�, ❑REPAIR TANK E::]CLOSE TANK&FILL IN PUCE [:]CHANGE PROCEDURE <br /> o YES a NO IF YES,DATE OM OD Y •� Y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION J9 UNKNOWN ❑ OTHER <br /> yw CHECK ONE ONLY <br /> O Fly ❑ UNDETERMINED ❑ SOIL ONLY JK GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wZ ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED [jPOLLUTION CHARACTERIZATION <br /> �y ❑ LEAK BEING CONFIRMED �. PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> O� f�svw lQlCtTAID) <br /> w <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY IRS) <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL ry5) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> F�An-l'►��r- SL c ass css rv�ew� w r11 6-� ►.a c�ssu ry40 de+e-v w t r.. <br /> -t-V...� •c.��� rrF -1'1,-� cow'�..w.i-v�ol.�-�r,c.. <br /> Rsc As le>bl <br />