Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCYHAS STATE OFFK OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ <br /> REPORT BEEN FLED? <br /> YES NO ❑ YES ❑ NO REPPORTED THIS: FORMATIONRTO L CGN L'O ICKN ANT <br /> PURSUQ SECTS 25iK7 OF <br /> REPORT DATE CASE i THE HEALTH AND 5AFfY ODDS <br /> SIGNED OAT <br /> NAME OF INDIVIDUAL F LING REPORT PHONE SIGNATURE <br /> w REPRESENTING ❑ OWNERIOPERATOR ❑ GlONALBOARD COMPANY OR AGENCY NAME /gyp <br /> wO LOCAL AGENCY ❑ OTHER <br /> rr ADDRESS <br /> STREET <br /> STATE Yp <br /> NAME CONTACTPERSON PHONE <br /> A �,� �4 T 7W- <br /> �' UNKNOWN <br /> ADDRESS 7 �� <br /> a <br /> cc <br /> 71101 -- at STREET` 2- • 4 tVtlL4 Cm, V/V L/� STATE CP,- <br /> FACILITY <br /> "FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> t� r Ir <br /> i ADDRESS <br /> 1 5T»., S— S7oc��,v' NT, 9sP <br /> hCROSS STREET TYPE OF AREA ❑ OMMERCIAI INDUSTRIAL a RAL TYPE OF BUSINESS � RETAIL FUEL STATION <br /> G A ii1z7eg-- a RESIDENTIAL OTHER a FARM a OTHER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> Z W S vd w a crC `T r-� D GST W1 <br /> w� <br /> REGIONAL PHONE <br /> Z C v rZtu ' G.B c f—S6 or <br /> 0) (7) - NAME QUANTITY LOST(GALLONS) <br /> LU 17L2 UNKNOWN <br /> 0 (2) <br /> �- <br /> ❑ UNKNOWN <br /> i DATEDISCOVERED /!Y)i HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> cc UNKNOWN F-1REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> ,y M M D D r Y <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIRPIPING ❑ CHANGE PROCEDURE <br /> p ❑ YES ❑ NO IF YES,DATE M M o o v v ❑ OTHER <br /> u� SOURCE OF DISCHARGETANKS ONLYACAPACI MATERIAL CAUSE(S) <br /> ❑ TANK LEAK UNNliKNOWN OO ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREIFALURE <br /> c ❑ PIPING LEAK AGE YRS ❑ STEEL ❑ CORROSION ❑ UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w CHECK ONE ONLY <br /> V UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> cc ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> v y ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PRCGRESS NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> b ❑ CAP SITE(CO) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(08) ❑ EXCAVATE&TREAT(ET) ❑ PUMP a TREAT GROUNDWATER(GT) ❑� SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(MO ❑ NO ACTION REQUIRED(NA) OTHER(07) <br /> IrT <br /> ecel Ved reiev'5AOAI 7eV o N <br /> P7 U 6-s—r i lr�7/ f� Sf TP.i /�S`-+"55`N Q.t%v'� 6v i / 1 be I'a t-c a T'p �Y+ <br /> e „1-- © P Co N jktit -^ P <br /> I vt ei f't�.� h.�A,,�-tt r Pi GU.� e x <br /> 6 .� <br /> MSC 0517! <br /> �1 �J <br />