Laserfiche WebLink
- L)7 136) N. <br /> 777's 77 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINA-I I ITE <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY RVICES FOR LOCAL AGENCY USE ONLY p� r '1 <br /> ❑ YES ❑ NO REPORT BEEN FILED 7 YEs ❑ NO I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATI iiOL�ORDIN(TO F" <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET.ON,T�EG�P/{C Ok J+IIS FORAti <br /> REPORT DATE ' <br /> CASE ' <br /> nn // ii..h•!Vt !}rl1 C, •. <br /> S O 6p� oC/( p2/ SIGNED �) <br /> DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> m <br /> F o ti ( (0) � 0260 <br /> RE❑SENTINGWNER OPERATOR ❑ REGIONAL BOARD COMPANY OR A NAME LOCAL l AGENCY Fj <br /> ( J0-T-lPrER <br /> Er ADDRESS a.r/te �,n rr( os <br /> STREET CTY STATE <br /> tc <br /> I <br /> wNAME CONTACT ERS PHONE n <br /> In co SCO (/(/1'�C UNKNOWN (3/O) D oC rte© <br /> z¢ <br /> 0 a ADDRESS <br /> Lo <br /> �- 3 r' v- <br /> STREET CI STATEzip <br /> FACIL�ITY NAM (IF APPLICABLE) OPERAn V` N sco I ,I I� p�N ` �6 <br /> z rl\r�i V +r <br /> 0 <br /> ¢ ADDR SS Q / . <br /> //V R l orw�q m h �Cz,,� �o��uc'toll <br /> o <br /> J STREET CITY C NTY <br /> w IP <br /> CROSS BEET <br /> /•tle- <br /> 0LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z ( ) <br /> Z h c�h ©Ct �1/� n DC7 <br /> w w REGIONAL RD PHONE <br /> O <br /> a a ( ) <br /> E <br /> (7) NAME QUANTITY LOST(GALLONS) <br /> w O <br /> U <br /> <J © UNKNOWN <br /> m o (2) <br /> �z <br /> ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SYPURFACE fA ONITORING NUISANCE CONDITIONS <br /> Lu <br /> w OMI /MI Do� Jol r� ❑ TANK TEST ❑ TANK REMOVAL OTHER l/ [ S L( a� <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> } v�+ DD r �4 ❑ UNKNOWN ❑REMOVE CONTENTS [:]CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> w <br /> p HAS DISCHA E BEEN STOPPED 4 ❑REPAIR TANK ❑CLOSg TANK&/FILL IN PLACE CHANGE PROCEDURE <br /> o YES ❑ NO IF YES,DATE DM l�Ml Do � r ❑REPLACE TANK OTHER J ►l(mac �Q� <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> cla ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPI �/h��r h� / <br /> 0 KI <br /> U ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN OTHER (l(� Qh s 4? ( <br /> w w CHECK ONE ONLY K� <br /> �a <br /> C) ❑ UNDETERMINED ElSOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wcn ❑ NO ACTION TAKEN F7PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ❑ LEAK BEING CONFIRMED ❑ PRE INARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY Ce V <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> J (SEE BALK FON DETAIS) <br /> z ❑ <br /> oO CAP SITE(CD) F7EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) �- <br /> Lu F <br /> Q a ❑ CONTAINMENT BARRIER(CB) F-1 N CTION REQUIRED(N ) ❑ TREATMENT ATHTP(HU) KI <br /> VENTS IL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) �7 ( (�( / ✓l CI r� <br /> U) w-p S pyoc <br /> �c' �^ c� O S l 9 o <br /> kl <br /> 0 D / <br /> 0 <br /> l <br /> HSC 05(fi50) <br />