Laserfiche WebLink
9 <br /> F <br /> NDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> ENCY HAS STATE OFFICE OF EMERGENCY SERVICES 'FORLOCAL°AGENCY USEONLY <br /> S Np REPORTBEEN FILED? ❑ YES ❑ NO DISTRIBUTION SHOWN ON THEBY CERTIFYTHATI EMITRUCTTN SHEET OTHIS N THE BAOCK PAGES OFTHISACCORDING O THE <br /> ORM. <br /> DATE CASEt bn /I 411A ,DATENAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> w REPRESENTING F-1 OWNER/OPERATOR ❑ GIONAL BOARD COMPANY OR ENCY NAME® LL LOCAL AGENCY ❑ OTHER �1 N9 xe5� <br /> 8 <br /> ADDRESS{ azo O/f c ��(H� yrATE • �na / <br /> / rtM� <br /> ,y NAME CONTACT PERSON PHONE <br /> w, ALFeo / UNKNOWN C/ <br /> Oa n ADDRESS / 5b W/ R pdN i � / �� �� <br /> y l 7 R/ <br /> W <br /> � srNeer em srATe P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> AFIIV <br /> 0 <br /> �0Lnoel ( 39-87 <br /> V ADDRESS n <br /> 5-0 <br /> D �5 P / <br /> wG. ./0 �EO tV /� CITY '—CDOVJ y G <br /> m CROSS STREET <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> =W — � N ( -3 � <br /> w n REGIONAL BOARD PHONE <br /> �a <br /> H (�) NAME QUANTITY LOST(GALLONS) <br /> W 7� Ya ��n.► 0�Iron A� f301n/S ❑ <br /> UNKNOWN <br /> iw <br /> a3 <br /> N Z <br /> ❑ UNKNOWN <br /> DATEI DISCOVERED HOWDISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> i <br /> NI M D Y Y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> ❑ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> M D Y Y '- <br /> HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE O <br /> o ❑ YES ❑ NO IF YES,DATE M MI DI J Yl r REPLACE TANK TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢� ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> a <br /> m0 ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> ww CHECKONEONLY <br /> ❑ UNDETERMINED ❑ SOIL ONLY PS GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> W Z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ¢r ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> Oy ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> 4�evw ra/oer� <br /> z <br /> CAP SITE(CD) EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> O 4 ❑ ❑ ❑ <br /> zU ❑ CONTAINMENT 13ARRIER(CB) ❑ NO ACTION REQUIRED INA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENTSOIL(VS) <br /> W 4 <br /> ❑ VACUUM EXTRACT(VE) ❑ <br /> OTHER(OT) <br /> w4 Si e Q SSt Srr - (4/i LL �7G <br /> reAJJA/Aeow fa d,rrki-rµlr e, Ke,A,� 1A All iwjqTipw k:5 <br /> &A rseek by 4 <br />