Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK' <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> ❑ YES NO REPORT BEEN FILED9 FOR LOCAL USE <br /> ❑ YES �X NO I HEREBY CER71FYTHAT I HA U/II A , <br /> REPORT DATE CASEN DISTRIBUTION SHOWN ON TH <br /> NAME OF INDIVIDUAL FILING REPORT SIGNED <br /> PHONE <br /> 11 0 UIQ CO. � Iro>1 f/1 kh (2D( ) toy" ') L <br /> w REPRESENTING ❑ OWNER/OPERATOq / <br /> ¢ ❑ REGIONAL BOARD COMPANY OR AGENCY NAN <br /> S LOCAL AGENCY ❑ OTHER �;��/✓l��/- <br /> ADDRESS / <br /> STREET/ [ <br /> cm <br /> z¢ 10RESS <br /> E � L�eS-� CONTACT PEflSON <br /> �S l IL❑UNKNOWN M r «I <br /> w a �(\� '(p 17r' - C I I4 I I I✓ " v (.. <br /> ¢ F U l� <br /> F CILITY NAM E(IFAAP'1TP�LICAB E) OSTATE <br /> PE <br /> ��q m�� PHON�� 'J7JP(7J7j0 <br /> vO W lY� <br /> ADDRESS V, — D <br /> O <br /> J <br /> ('n'n <br /> y CRO S STREET q5)4 <br /> badZIP <br /> 0 LOCALAGEENCY <br /> _z m AGENCY NAME I .B/ CO/y�N/]TA�/C/T,PERS'O/N <br /> ~w V) LI, 11/�' ( P I IIPLr /,r PHONE <br /> w w REGIONAL BOAR VI! r I D (q�/9i <br /> G ( l/lam PHONE <br /> tI,{yV�'_y/0�� q/V <br /> w NAME lug/ —��/ <br /> Z QUANTITY LOST(GALLONS) <br /> i UNKNOWN <br /> w <br /> i DATE DISCOVERED HOW DISCOVERED ❑ UNKNOWN <br /> INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> M u I c y y ❑ TANK TEST ❑ TANK REMOVAL ® OTHER <br /> m DATE DISCHARG EBEGAN <br /> a METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M G YlI ® UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK B REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEENSTOPPEDT <br /> {'� 8 UJ{� ❑REPAIR TANK ❑CLOSE TANK d FILL IN PLACE <br /> C5 ❑ YES � NO IF VES,DATE REPAIR <br /> PROCEDURE <br /> M n y y ❑REPLACE TANK O OTHER_ I)4/v)0 w A <br /> SOURCE OF DISCHARGE <br /> h <br /> ES) <br /> CAUS <br /> a ❑ TANK LEAK UNKNOWN <br /> y O F-1 PIPING LEAK ❑ OTHER ❑ OVERFILL ❑ RUPTURE/FAILURE E] SPILL <br /> ❑ CORROSION UNKNOWN El OTHER <br /> ya CHECK ONE ONLY <br /> Q CH♦C ONEONTLY MINED F-1 SOIL ONLY ❑ GROUNDWgTER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> ¢z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED <br /> �y ® ON <br /> LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUPTION MONITORING <br /> IN <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP <br /> UNDERWAY MONITORING IN PROGRESS <br /> CHECK APPROPRIATE ACTION(S) <br /> ❑ CLEANUP UNDERWAY <br /> <z I=�%.c+rwnEreul ED E%CAVATEE DISPOSE(ED) ❑ REMOVE FREE PRODUCTFP <br /> ( ) ❑ ENHANCED BIO DEGRADATION(1T) <br /> W O ❑ CAP SITE(CD) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP 8 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) VENT SOIL <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) r <br /> C ❑ (VS) <br /> IU <br /> HSG 4 lAs% <br />