Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFILED?EMERGENCY SERVI POREBY CERGENCY USE ONLY <br /> L(^�"�^' REPORT BEEN FILED? I HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE. <br /> YES YES REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SE ION IAU7 OF <br /> CASEN THEN L ANO SAF�'l CODE��� <br /> REPORT TE <br /> /���rrr/1 j�J�/�( �/l �/1� /$�" TE <br /> VM NAM "I -p V r V <br /> NAME OFINDIVID�IL�NG REPORT <br /> PHONE� SI URE <br /> COMPANY OR AGENCI NAME <br /> 0 REPRESENTI O OWNEROPERATOR REGIONAL BOARD <br /> O <br /> gLOCALAGENCY OTHER <br /> ADDR ��+ �(�I <br /> u. 13W o 5 ffi TE ZR <br /> NAME CONTACT PERSON PHONE <br /> LH <br /> UNKNOWN S ( `/ <br /> n ADDRESS � Af�� <br /> 6 lg� VL V LRV O/ l <br /> ITE LP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ( ) Lu <br /> ADDRESS Low 1 J4I'T/E/ eA & ltd <br /> CROSS STREET TYPE OF AREA MMERCIAL O INDUSTRIAL O RURAL TYPE OF BUSINESS O RETAIL FUEL STATION <br /> m � O RESIDENTIAL O OTHER O FARM OTHER <br /> g LOCAL AGENCYAGENCY NAME ODNTACT PERSON PHONEp� y) <br /> iw < ( Y ( � <br /> RGI AL BOARD PHONE <br /> (I) NAME QUANTITY LOST(GALLONS) <br /> KNOWN <br /> (2) <br /> �- UNKNOWN <br /> Z <br /> DATEDISCOVERED /Q HOWDISCOVERED O INVENTORY CONTROL O SUBSURFACE MONITORING NU)SANCE CONDITIONS <br /> 2 <br /> ONRM 0o T+ o 9r� v TANK TEST O TANK REMOVAL �THER <br /> 3 DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPL"@ M M o o y r �riUNKNOWN / 0 REMOVECONTENTS 0 REPLACE TANK CLOSE TANK <br /> M HASDISCESP <br /> GEEBBEEN TOPEDATE D M-T M / D r b r E REPAIRTANK REPAIRPIPWG a CHANGE PROCEDURE <br /> NO <br /> v O OTHER <br /> \Ziu� SOURCE OF DISCHARGE TANKS ONLYYCAP^ACITY MATERIAL CAUSE(S) <br /> q O TANKLEAK UNKNOWN �V GAL. FIBERGLASS O OVERFILL O RUP REFA0.URE <br /> (�l PIPINGLEAK AGE YRS STEEL O CORROSION UNKNOWN <br /> O OTHER OUNKNOWN O OTHER O SPILL O OTHER <br /> ww OHECK ONE ONLY <br /> UNDETERMINED O SOI NLV 21--GROUNDWATER O DRINKINGWATER. (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKO NLV <br /> 2 N <br /> Z SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) O CLEANUP IN PROGRESSO SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> Uy O NOACTIONTAKEN O POST CLEANUP MONITORING IN PROGRESS O NO FUNDS AVAILABLE TO PROCEED O EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> O CAPSITE(CO) O EXCAVATE B DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) O ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT 13ARRIER(OR) O EXCAVATE S TREAT(ET) O PUMP&TREAT GROUNDWATER(GT) O REPLACE SUPPLY IRS) <br /> 0 TREATMENT AT HOOKUP(HU) O NO ACTION REOUIRED INA) O OTHER(OT) <br /> -71A Sjo <br /> � �"+�•on�� c'tm /U <br /> l <br /> KSC O514HZ) <br />