Laserfiche WebLink
i <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES ❑ NO REPORT BEEN FILED 7 ❑YES ❑ ND REPORTED THIS NFORMATIONI HEREBY CERTIFY THAT I AMATO LOCAL OFFICALSN PURSUANT DESIGNATED GOVERMENT EMPLOYEE <br /> TO SECTION 251607 OF <br /> REPORT DATE CASE* THE HEALTH ANDSiFYY CODE. <br /> 8 ?Y SIGNED — --DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNA - ) <br /> 1 (24) yWioq4b� <br /> W <br /> REPRESE ❑ OWNERIOPERATOR ❑ LEGIONALBOARD COMPANY OR AGENCY NAME <br /> o LDCALAGENCY ❑ OTHER <br /> /55 iC� <br /> a ADDRESS <br /> / STREET WY �/v STATE <br /> NAME /J CONTACT PERSON PHONE <br /> kLS -77 /C O� ❑ LINK WIN <br /> ( ) <br /> Y1 y ADDRESS <br /> /6 STREET CITY <br /> STATE ap <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ` ADDRESS /- 1 <br /> tT �. lv?wl CITY c NTY ap <br /> yCROSSSTREET TYPEOFAREA ❑COMMERCIAL❑INDUSTRIAL ❑RURAL PEOFBUSINESS <br /> Q RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCALAGENCV AGENCYNAME CONTACFPERSON PHONE <br /> REGIONAL BOARD P ) ' <br /> PHONE <br /> y (() NAME QUANTITY LOST(GALLONS) <br /> 5;�"UNKNOWN <br /> m <br /> ❑ UNKNOWN <br /> I- DATEDISCOVERED HOWDISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING <br /> y� ❑ NUISANCE CONDITIONS <br /> M 4921 DD o y y ❑ TANKTEST /TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M o o v Y UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TIWK CLOSE TANK <br /> HAS DISC EBEEN STOPPED? ❑ REPAIRTANK ❑ REPAIRPPNG ❑ CHANGE PROCEDURE <br /> o YES ❑ NO IF VES,DATE <br /> 7M Ml ol DI YJ Y ❑ OTHER <br /> u� SOURCE OF DISCHARGE TANKSONLYACAPACITY MATERIAL CAUSE(S) <br /> q ❑ TANK LEAKUNKNOWN GqL, ❑ FIBERGLASS <br /> S ❑ OVERFILL ❑ RUPTUREFAILURE <br /> F-1PIPINGLEAK AGE YRS ❑ STEEL ❑ CORROSION Ew�UNKNOWN <br /> F-1UN <br /> OTHER KNOWN E::] OTHER <br /> ❑ SPILL E::] OTHER <br /> W CHECK ONE ONLY <br /> ❑ UNDETERMINED ❑ SOILONLV GROUNDWATER ❑ DRINKNGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> g CHECKONEONLY <br /> $ ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ❑' NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED <br /> ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTON(S)(SEE BACK FOR DETAILS) <br /> a ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) n REPLACE SUPPLY IRS) <br /> ❑ TREATMEENNTAT HOOKUP(HU) O NO ACTION REQUIRED INA) �OTHER(OT) <br /> F �7` N /y1Yl/ Q G�f CZ¢6G�17LGu u/( G� L e R.j <br /> MumareTl <br />