Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATIOA9l-&tFf# <br /> EMERGENCY HASSTATEEOFFICEOFMEAGBNGICSERV` FOR LOCAL'AGENCY USE ON M NT l I..IEaL7.'.. <br /> REPOR ILeDr 1 HEREBY CERTIFYTHAT 1 ISTRI9UTEDTHISINFMV <br /> ❑ VES ❑ VES ❑ NO Ad' T <br /> REPORT DATE 1) 1 S THE INSTRUCTION SHEET <br /> O G <br /> G CASE s <br /> D 4_4 <br /> I,STR <br /> NAME O INDIVIDUAL FILING REPORT _ 7 <br /> m c\%j• �^ ��D`L - � SI ATURE BATE. <br /> w REPRESENTING (ff�` COMPANY OR AGENCY NAME <br /> OWNER/OPERATOR ❑ REGIONAL BOARD <br /> R ❑ LOCAL AGENCY OTHERrr <br /> 111�W <br /> W <br /> ADDRESS// /Jnr, <br /> -L I cm WAW <br /> 21P <br /> Q NAME CONTACT PERSON PHONE <br /> z T7(J L Llo(J <br /> i¢ A7wz ❑ UNKNOWN �. <br /> a a <br /> ADDRESS <br /> FACIL NAMCE(IFAPPLICASLE) R OR PHONE <br /> 454— aQ�'rq <br /> a <br /> ADDRESS <br /> w 'J�L V/' Cm kL Ul <br /> COV 21P <br /> y CROSS REEF i <br /> 4m tv�V� <br /> i ALAGENCY AGENCYNAME {/{ TAC PERSON PHONE <br /> F y - <br /> RECJON <br /> W D <br /> S: - <br /> a�e,� �- <br /> y 11) NAME - QUA TITYL <br /> wC a> PLO <br /> / `-^ T-1 ^L I � ❑ UNKNOWN <br /> m> (2) <br /> N <br /> ❑ UNKNOWN , <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING _n�7 NUIS NDrTuNS <br /> DD l Y r ❑ TANK TEST ❑ TANK REMOVAL EOTHER <br /> METHOD USED TO STOP <br /> m DATE DISCHARGE BEGAN UNKNOWN ❑REMOVE CONTENTS <br /> IS❑CLOSE TANK BR MOVE E(CHECK ALL THAT PAY)❑REPAIR PIPING <br /> a <br /> w o r r <br /> 8 HAS DISC BEEN STOPPED 7 ^ ❑REPAIR TANK ❑CLOSE TA &FILL IN PLACE ❑CHANGE PROCEDURE <br /> VES ❑ NO IF VES,DATE V & � �� ❑REPLACE TANK Q OTHER p 1(f <br /> M D Y <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL I <br /> �U ❑ PIPINGLEAK OTHER ❑ CORROSION ❑ UNKNOWN �6THER r(, <br /> ww CHECKONEONLV <br /> RT�UNOETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTS <br /> CHECK ONE ONLY <br /> wZ ❑ NOACTK)NTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN a2rCASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUPUNDERWAV <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J Pff swR FA LET.Y81 <br /> �p ❑ CAPSITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> ~ CONTAINMENT 13ARRIEfl(CS) NOACTK)N REGUIRE NA) TREATMENT AT HOOKUP(HU) VENT SOIL <br /> ❑ VACUUM EXTRACT(VE) BOTHER(OT) 1 <br /> m <br /> z <br /> w <br /> f <br /> brcavv` eh v`( aud�� pec �l�z . <:!-c <br />