Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMERG'NCV SERVICES FOR LOCAL AGENCY USE ONLY <br /> NPS/ DSIGNATED GOVERMENT EMPLOYEE <br /> REPORT BEEN FILED7 LI�J(YES ❑ � I HEREBY CERTIFY THAT I AM AND THAT I A <br /> _ REPORTED THIS NFORMATICNAT ELO AL OFFICIALSN <br /> NPURSUANT TO SEVEC <br /> ❑ YES TON 25160.7 OF <br /> REPORTOATE CASE• THE HE AND YCOO� ��ryryNr <br /> .r� 1 t 1 <br /> DATE — <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIG T RE <br /> C harlx uN aiI - - 3 o „e <br /> REPRESE ING ❑ OWNERIOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> ALAGENCY ❑ OTHER N <br /> a <br /> ADDRESS q�,� <br /> a U u STREET CITY l//1 <br /> Sf,E 5�2-0zIP <br /> NAME CONTACTPERSON PHONE <br /> z¢ •L r ❑ UNKNOWN /U G /7[i (fit 1 569-32y� <br /> E a ADDRESS <br /> N cJ rA <br /> STREET N CRY SPATE zIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> NCk MA k <br /> ADDRESS / �•) <br /> J— ,V/ N r Courm P <br /> CROSS STREET 'Tv sTREEr TYPEOFAREA ❑COMMERCIAL❑INDUSTRIAL E:]RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> w E::]RESIDENTIAL �OTHER ❑ FARM ❑ OTHER <br /> LOCALAGENCY AGENCY NAME _ CONTACTPERSON PHONE <br /> ��, ,� rarlrter <br /> hark- <br /> P: UN t�11�6g 3Yy0 <br /> w� REGIONAL BOARb <br /> PHONE <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> DR/LNKNOWN <br /> O 1� 1 <br /> ❑ UNKNOWN <br /> DATE DISCOVERED D v O Y HOW DI TA ERRED T ❑ TAVENTOROVA CONTROL ❑ OTHER MONITORNG ❑ NUISANCE CONDITIONS <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ElREMOVECONTENTS ❑ REPLACETANK ❑ CLOSETANK <br /> M M M 0 Y Y <br /> HAS DISCHARGE BEEN STOPPED 7 ❑�j/REPAIRTANKK•J" ❑ REPAIRPIPING ❑ CHANGEPROCEDURE <br /> p ❑ YES [:] NO IF VES,DATE M M �o / 01 <br /> _1 <br /> l/ Y LLJ OTHER <br /> SOURCE OF <br /> ❑ ANKLEAKRGVUNKNOWN TANKS ONLYICAPACITY MATERIALOFIBERGLASS CAUS <br /> ❑(OVERFILLPNREIFAEURE <br /> ❑ PIPINGLEAK AGE YRS ❑ STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER FK!l UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> ww CHECKONEONLV <br /> p� ❑ UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER E] DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F, CHECKONEONLY <br /> F-1 SITE <br /> RESS(DEFINING EXTENT OF <br /> ANUP IN <br /> SIGNED <br /> ANUP <br /> MPLETED OR <br /> ❑ OACTIONTTAKENNI❑OPOST CLEANUP MONITORING IN PROGRESS❑❑ANO FUNDS AVAILABLE TOPROCEEDOFF0 EVALUATING CLEANUP ALTERNATIVES Q <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) 1 <br /> �zzp ❑ CAP SITE(OD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) r <br /> wF PUMP&TREAT GROUNDWATER(GT) REPLACESUPPLY <br /> 2� ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE6 TREAT(ET) ❑ ❑ <br /> ❑ TREAyTMEENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED INA) <br /> r A❑ OTHER(OT) <br /> MSO W(W) <br />