Laserfiche WebLink
UNDERGROUND STORAG tJK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE O <br /> REPORTBEFOR LOCAL AGENCY USE ONLY <br /> R <br /> E:] YES ❑ NO y I HEREBY CERTIFYTHATI upyE rneraiaurPn ru clNrlxiMATIONACCORDING TOTHE <br /> REPORT <br /> DISTRIBUTI EI GTX)N SHEET ON THE BACK PAGE OF T FOR <br /> CASETE • <br /> mi 04 l NVIRONMENTAL HEA `r <br /> NA E IN UAL FILING REPORT SIGN ��� oar <br /> &7- <br /> I a <br /> REPRESENTING 0 ERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> ¢ ❑ LOCALAGENCY ER <br /> S <br /> w <br /> ¢ ADDRESS <br /> 167 <br /> 1// cm a eTe nP <br /> w NAME CONTACT PERSON PHONE <br /> m <br /> i ❑ UNKNOWN ( I <br /> w n ADDRE S <br /> ¢ 1 [U <br /> cm arATL�-�- i lP <br /> FACIL E APPLICABLE) OPERATOR PHONE <br /> o <br /> ADD ESS <br /> l �1. <br /> Eu cm cou nP <br /> y CROSS STREET <br /> L NCY AGENCY NAME TACTPERSON EHQNE <br /> w <br /> Z <br /> a REGIONAL IS 0 <br /> OARD PHONE <br /> � IN <br /> w (1) NAME OUANTIT'LOST(GALLONS) <br /> Ow <br /> FJ_ v <br /> 02 <br /> y I <br /> ❑ UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 1 1O ❑ TANK TEST ❑ TANK REMOVAL � OTHER I <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M c Y Y (�UFKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED? /'� ❑REPAIR TANK O CLOSET NK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> 0 ��3 E] NO IF VES,DATE a ///i 5 q� aREPLACE TANK �TH <br /> SOURCE OF DISCHARGE SMI CAUSE(S) <br /> jI ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> F-1 PIPINGLEAK OTHER <br /> �' ❑ CORROSION ❑ UNKNOWN -OTHER / <br /> yww CHECKON ONLY <br /> O UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> ❑ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENTWORKPLANSUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> H ❑ LEAK BEING CONFIRMED ❑ PR IMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATION PLAN ASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ <br /> CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> Iag surcaoeruq <br /> 0 0 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(Ep ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> wF <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REOUIRED( ) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) <br /> y <br /> z <br /> w <br /> s <br /> &IV Hsc (�al <br />