Laserfiche WebLink
—('cz -5 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> YES NO <br /> REPORT BEEN FILED 7 YES NO I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ <br /> DISTRIBUTION SHOWN ON THE WSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. <br /> REPORT <br /> ,,��DATE � 1`^ CASES <br /> o ( <br /> ml ` .1 2 OL `' r S)GNED DATE <br /> NAME OF INDIVIDUAL FILING REPORTP HONE SIGNATURE <br /> m <br /> o REPRESENTING OWNE PE R Fl REGIONAL BOARD COMPANY OR AGENCY NAME <br /> g ❑ LOCAL AGENCY ❑ OTHER C� Ccs <br /> ADDRESS ��ry� my (� <br /> e O . +F..7�./► STREET VEIL/v CT• �RvcS.Iol STATE Z�, 03 8 <br /> Lu NAME CONTACT PERSON I PHONE <br /> co C/)¢ '>�� C-o" ��. ❑ UNKNOWN ( <br /> as <br /> ADDRESS <br /> V)a <br /> w <br /> cc STREET CRY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> c, bac. � MN, lY1e���1Nc• taa�) 93s <br /> a ADDRESS <br /> /` 7f(�/(� � a /Q� S� 9 S3�L <br /> OJ (`� �� .J -so. STREET 1\�7 �/W CRY ✓'Iwo C COUNTY�a V vq ZIP <br /> w <br /> ~ CROSS STREET <br /> 0 LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> zN <br /> w a ��� Ccs - zoo, \e\\�N (2c�1 ) <br /> w w REGIONAL BOARD vPHONE <br /> J(7 <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> a �e ❑ UNKNOWN <br /> M> (2) <br /> MZ <br /> ❑ UNKNOWN <br /> z DATE DISCOVERED O► HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING E] NUISANCE CONDITIONS <br /> ui <br /> uI uI L oI o •Y r <br /> U ("' ❑ TANK TEST ❑ TANK REMOVAL ® OTHER jAo N`Tp�a A\411M <br /> < DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a 1 I UNKNOWN REMOVE CONTENTS CLOSE TANK d REMOVE <br /> Lu <br /> lYu 2 leo r� ❑ ❑ E:] TVE:]REPAIR PIPING <br /> >O HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK E]CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE PROCEDURE <br /> o YES [:] NO IF YES,DATE (o tp C1 v Y ❑REPLACE TANK ® OTHER S�l �UU�1J @ro.-rVkl 1W Q <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> Jw <br /> cc �5 ❑ IANK LEAK ❑ UNKNOW4 ❑ OVeNrILL LJ HuP-i-UREJFA)LUHE U JYILL <br /> Uv <br /> ) ® PIPING LEAK ❑ OTHER I ❑ CORROSION UNKNOWN ❑ OTHER <br /> N La CHECK ONE ONLY N0N Q. <br /> v ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> a:y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY (� <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) \' <br /> J (SEE SACK FOR OETALM �\ <br /> E5 O ❑ CAP SITE(CD) ❑ EXCAVATE 6 TREAT(ET) ❑ PUMP 6 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) ,) <br /> w< ❑ CONTAINMENT BARRIER(CB) NO ACTON REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ¢ ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> (� De G,�, '0� ,f•1� ��p,�V �'�„ �l/� VIA . wa0cn <br /> O N 1 1 S U Y G/✓� V' <br /> ���. v �, ,, Te„n w� sk„� bwcv , �� sip Q'y' <br /> 0 <br /> �N�x.o.?�e 'a, akE, ' w.A Y l I e fA�rLs <br /> t1 arc n� eNv��c.„rna�.�r NA <br /> KSC 05(&W <br />