Laserfiche WebLink
HSCw 4W) <br />unuthUNUUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />❑ YES pr NO REPORT BEEN FILED? <br />Fx <br />JEEI�HE YCY US NLY <br />❑ YES ❑ NO <br />M TEDGOVERNOFFICIALS <br />AT I HAVEREPORTOATE <br />EMT LOO <br />CASE• <br />.RTHAT <br />TO ENT <br />SECTION <br />TFTY <br />OM2M IaF-v 5-v <br />NAME OFINDIVIDUAL FILING REPORT PHONE <br />S <br />DATE <br />m <br />SIGNATOR <br />okv*lc) Co.rls (zo9) 468—?, <br />REPRESENTING ❑ OWNEWOPERATOR ❑ REGIONAL BOA RD <br />COMPANY OR AGENCY NAME <br />S <br />LOCAL AGENCY ❑ OTHER <br />J <br />�ql. So9 �.ih Local �i e,�t� 01S"7✓:<� <br />¢ <br />ADDRESS <br />Ifbo 1 r_ N4�aid . p��- g�x z <br />S4�<I���r cA 4szo, <br />� <br />m <br />NAME <br />V... Deb Sc4�ol Des+.ic"f <br />r'm' IP <br />CONTACT PERSON STATEPHDNE <br />P <br />Loi. <br />�aL-ir[olh <br />❑ UNKNOWN <br />ADDRESS <br />G'1 Icer 5-�r sc (Zdj) 47-; -S�8 <br />H a <br />b�VS Iiwr✓S�Y Q�K� <br />J1y<,cCq GA �azo� <br />FACILITY NAME (IF APPLICABLE) <br />C'm <br />STATE 711P <br />OPERATOR <br />(r` y <br />L,1r C01r �/�•�?i E.d S�\seol DIS 1r: G� <br />y� PHONE <br />AI�r <br />giTG✓'Swn <br />a <br />ADDRESS <br />ii°1 Ft nrrKSl'Ur✓ plwt¢. <br />.7S�,c�.r ..... <br />S Z0ltriy� <t3'20 <br />�-q <br />STREET _< <br />CROSS STREET TYPE OF AREA ❑ COMMERCIAL ❑ INDUSTRIAL ❑ RURAL TYPE OF BUSINESS <br />D 1' y ❑ RETAIL FUEL STATION <br />-[[::]FARM <br />OQr. 1'ToI F' RESIDENTIAL❑OTHER 'OTHER $c1+�el <br />LOCALAGE'NIC�Y NAME <br />CONTACTPERSON PHONE <br />w <br />'jAGENCY <br />n1� ++ <br />�'^ 1i 0e1 .:�r LeC4I j�C'i5It1^ 1J1S�ric1 <br />Gear�S NibF-3vvo <br />fluid <br />J (204) <br />u37w <br />REGIONALBOARD <br />PHONE <br />a� <br />Ce,4✓ l �la1�t <br />p <br />Godo <br />Oo <br />y <br />w <br />Il) NAME <br />QUANTITY LOST (GALLONS) <br />Grltwd-cd GaSolitie- <br />UNKNOWN <br />- <br />❑ UNKNOWN <br />b <br />DATEDISCOVERED <br />HOWDISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING E:]NUISANCE CONDITIDNS <br />6 <br />O M 2 M 1 DI D V -v k v <br />w TANK TEST ❑ TANK REMOVAL ❑ OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br />OM 2 Ml I oI -+o �yl U v ❑ UNKNOWN <br />REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br />HAS DISCHARGE BEEN STOPPED 9 <br />❑ REPAIR TANK ❑ REPAIRPIPING ❑ CHANGEPROCEDURE <br />p <br />-?-o �v <br />�z YESE] NO IFYES.DATE OM 2H l <br />❑ OTHER <br />D v <br />SOURCE OF DISCHARGE <br />TANKS ONLYA:APACITY <br />MATERIAL <br />CAUSE(S) <br />p <br />❑ TANKLEAK rZ UNKNOWN <br />(o, 00o GAL <br />❑ FIBERGLASS <br />❑ OVERFILL ❑ RUPTUREIFAILURE <br />❑ PIPING LEAK <br />AGE 4 VPS <br />STEEL <br />❑ CORROSION W UNKNOWN <br />❑ OTHER <br />❑ UNKNOWN <br />❑ OTHER <br />❑ SPILL ❑ OTHER <br />CHECKONEONLY <br />ywy� <br />K3� <br />❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />F <br />CHECKONEONLY <br />< <br />❑ SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />$�$ <br />ISSNOACTCNTAKEN <br />❑ POST CLEANUP MONITORING IN PROGRESS <br />Q NO FUNDS AVAILABLE TO PROCEED Q EVALUATING CLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTIONS) (SEE BACK FOR DETAILS) <br />a❑ <br />CAP SITE (CD) ❑ EXCAVATE B DISPOSE (ED) <br />❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />,w3,K� <br />�� <br />❑ CONTAINMENTBARRIER(CB) ❑ EXCAVATE &TREAT (ET) <br />❑ PUMPA TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY(RS) <br />TREATMENT AT HOOKUP (HU) ❑ NO ACTION REQUIRED INA)){.. <br />❑ OTHER(OT) <br />D❑ <br />FG'PF.54� vVoFG.d d�r.y.� prtclSSi.r �S1 <br />1 <br />HSCw 4W) <br />