Laserfiche WebLink
mwm(w <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />FOR LOCAL AGENCY J_ONL <br />❑ <br />YES ��/� REPORT BEEN <br />FLED 7 ❑ YES � <br />I HEREBY CERTIFY T AM D SI TED G VERNMENT EMPLOYEE AND THAT I HAVE <br />CJ <br />REPORTED THIS TI T AL OFF IALS PURSUANT TO SECTION 25180.7 OF <br />THE HEALTH AN E <br />REPORTDATECASES <br />OM <br />2 <br />O M J o gr Vr <br />SIGNED __ — DATE <br />NAME OF INDIVIDUAL FLING REPORT <br />PHONE <br />SIGNATURE <br />yrox'3v <br />m <br />� <br />REPRESENTING ❑ OWNEIVOPERATOR ❑ REGIONAL BOARD <br />COMPANY OR AGENCY NAME <br />OTHER <br />^ } <br />1�k 1J\S�✓�c1 <br />AGENCY L] <br />ADDRESS 1{.,� ^ -1 <br />"'0% SZ� <br />���200 p �� GTAE <br />SHEE�O <br />\ P <br />NAME <br />CONTACTPERSON PHONE <br />y� <br />Ei��Can <br />❑ UNKNOWN <br />Vitvr koor¢.- (a�t)�ss'z 'A <br />u <br />w <br />ADDRESS <br />11LJ/'r 0'I <br />c- o qS3 'Y <br />$ 4ai F �A. <br />p��� <br />cm STATE ZIP <br />F ITY NAME(IF APPLICABLE) <br />OPERATOR PHONE <br />Dart. <br />�GJr J�oe,t (2^al)f3S'^2rs� <br />5��ij <br />ADDRESS" <br />\. <br />S4�i1 F S� <br />ga -CITY. c-4IIITY 4S'3��1 <br />ZIP <br />CROSS STREET <br />TYPE OF AREA ❑COMMERCIAL ❑ INDUSTRIAL ❑ RURAL <br />TYPEOFBUSINESS EE� ETAILFUELSTATION <br />❑ RESIDENTIAL O OTHER <br />❑ FARM O OTHER <br />AGENCYNAIMEE, <br />OONTACTPERSON <br />PHONE <br />?� <br />`LOCALAGENCY <br />'` -1- <br />�oA Lcc.a1 <br />.:, �. L-}La1�'In <br />.3p •. <br />;y <br />REEGGK`I.B11OA <br />�OJCION <br />P`HO1.NE <br />GYTJ�I v0�11f <br />1' S <br />(I (Y)3 rp I -.5% O'i <br />w <br />(�) <br />NAME QUANTITY LOST (GALLONS) <br />` <br />1� <br />\1 �1 <br />$� <br />GTV oIt✓..� �. u.r Lso\.. U�JORRNOWN <br />(2) <br />Ri <br />❑ UNKNOWN <br />DATE DISCOVERED <br />HOW DISCOVERED❑ INVENTORY CONTROL 5TISUBSURFACE MONITORING ❑ NUMVCECOFDMONS <br />s- / S -r Y <br />❑ TAW TEST ❑ TAW REMOVAL ❑ OTHER <br />MI MI DI ol v <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br />w <br />u IdD r r <br />'"'SOWN <br />❑ REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br />❑ REPAIRTANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED 7 <br />p <br />❑ YES E�!` 'NO IFYES,DATE <br />❑ OTHER <br />M .1 D D r Y <br />SOURCE OF DISCHARGE <br />TANKS ONLY/CAPACITY MATERIAL <br />CAUSE(S) <br />❑ TANK LEAK Ez�UNKNOWN <br />GAL. ❑ FIBERGLASS <br />❑ OVERFILL ❑ RUPTURE/FALURE <br />❑ PIPING LEAK <br />AGE YRS ❑ STEEL <br />❑ CORROSION K' UN KNOWN <br />❑ OTHER <br />❑ UNKNOWN ❑ OTHER <br />❑ SPILL ❑ OTHER <br />w�) <br />CHECKONEONLY <br />OF <br />UNDETERMINED a SOILONLY <br />O GROUNDWATER ❑ DRINKING WATER �(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />F <br />CHECKON ONLY <br />a <br />SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />80 <br />❑ NO ACTION TAKEN O POST <br />CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />o❑ <br />CAP SITE (CD) <br />❑ EXCAVATE 6 DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (m <br />❑ CONTAINMENT BARRIER (CB) <br />❑ EXCAVATE A TREAT (ET) ❑ PUMP& TREATGROUNDWATER(GT) ❑ REPLACESUPPLY(RS) <br />❑ TREATMENT AT HOOKUP (HU) <br />❑ NO ACTION REQUIRED INA) ❑ OTHER(OT) <br />S. co.,��_�.��a.► <br />a T�� v�1-.i.r� <br />mwm(w <br />