Laserfiche WebLink
E-� <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY MAB$TATE OFFIOE OF EMERG6rtK 861111M a <br /> LIQ <br /> ❑YES REPORiTSEENFLEO? p <br /> NI0 YES <br /> YES <br /> R�- <br /> FIEPORTDATE CASE• <br /> <` <br /> NAA�DF dVIDUALFIT PHONE ::::8KKINNA <br /> � <br /> REPRE9ENTNG ❑ ROPERATOR ❑ REeam BOARD COMPANY OR AGEhIGY NAME <br /> ACIENCY ❑ OTHERADDRESS <br /> `S <br /> yYsMY WATE 9Sp <br /> CONTACT PERSON PHONE <br /> UNKNOWNADORM <br /> 19831 At, D �,- Poad <br /> FACLITY NAME(F APPLICABLE) OPERATOR PHONE <br /> ADDRESS <br /> _7y <br /> Lc_J. <br /> CWVSTREET TYPE�OF AREA C3 COMMERCIAL C3 NOUBT111AL[3RURAL TYPE OF BUSNES$ F] RETAL R�JELSTATIORI <br /> Va-,& 4- LCJ" svwr IL ❑OTHER ❑ FAM dOTHER��LR 2I SLI d <br /> LOCALAGENCY AGENCY NAME OONTOCTPERSO= PHONE <br /> REGIONAL BOARD PHONE <br /> c ) <br /> (tJ NAME OUANYfTY LOST <br /> dATte 018COMERED HowcIACOVEREc ❑ NVENroRY cONTRaL ❑ BLJas1wACE MON70RNG p NUISANCE OONDITION6 <br /> r Y <br /> ❑ TAWTE$T �Y�TAWNAI NAL ❑ OTHER <br /> DATE DISCHARGE RGE BEGAN METHOD USED TO$TOP DISCHARGE ALLTENT APPLY) <br /> aj pi ER'-=- [20REMOVEOONTENTS ❑ REPI M TAW ❑ CLOSE TANG <br /> HAS DWHARCIE BEEN STOPPED 7 REPAIR TANG � REPAIR PPNG ❑ CHANGE PROCMUI' <br /> YES ❑ NO FYES.OATE fj 24 _54 Qr I r 11d OAR <br /> SOURCE OF DISCHARGE TANKS ONLY+CAPACITY MATERIAL CALAM <br /> ❑ TANK LEAK �1W1,00WN GAL. ❑ FIBERGLASS ❑ OVERFLL ❑ RUPTUREWALURE <br /> ❑ FIF LEAK AGE YRS �Smil. ❑ CORRO$KJN �1NOiOWN <br /> ❑ OTHER UMKNgMI ❑ OTHER p SPILL ❑ OTHER <br /> CHEM ONE ONLY <br /> ❑ UNOETER WM SOL ONLY ❑ GROLSOWATER ❑ DRNKNG WATER• POWK ONLY F WATER WELLS NAVE ACRJALLY BEEN AFFWUDI <br /> CFIECKON4ONLY <br /> ❑ SITE NVESTKIATON N PROGRESS WANG O)CfENT OF PROBLEM) ❑ CLEANUP N PROGRESS❑ SIINED OFF RCLEANJP COMPLETED OR UNRNl0ESSARY) <br /> ❑ NO ACTION TAKEN ❑ POST OXANJP MONITORNG N PROGRESS ❑ NO AMOS AYALASLE TO PROCEED ❑ EVALUATNG C1,"W ALTERNATIVES <br /> CHECK APPROPRIATE ACTION($)(SEE BACK FOR DETAKA <br /> ❑ CAP SITE(CDJ ❑ EwAVATE L ORSPOSE(EDJ ❑ REMOVE FREE PROOUOT(FPJ ❑ FINANCED BIO DEORACATIDN(fiy 1-0 <br /> ❑ CONTANMENT BARRRER(CB) ❑ ExcAvATE&T REAT(ET) ❑ PLJMP A TWAT GROUNDWATER On ❑ AEpLAC::SI PPLY(RSJ <br /> ❑ TREAufENT AT HOOKUP(NUJ ❑ NO ACTON REQUIRED(NA) ❑ OTSER(OT) <br /> /,�1uLl L 2t' d xl &jog-62 an.--?-ettrnc, -u�•� t V gcc <br /> hem ne <br /> >�mI�I <br />