Laserfiche WebLink
V' <br /> UNDERGROUND STORAGE T UNAUTHORIZED RELEASE(LEAK)/C§ITAIVIINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY s MR LOCAL AGENCY USE ONLY x � <br /> REPORT BEEN FLED 7 (- <br /> : -. <br /> ❑ <br /> YES No YES Q NO tHEREBY:cERTFrTHur�HAvETHMwAORMATarrircWRouicm�(E . <br /> L1N w ON THE BACK PAGE k <br /> REPORT DATE CASE s <br /> 40NAWTE <br /> EOFINDIVIDUAL. REPORT PHONE <br /> rI <br /> m <br /> W <br /> =LOCAL <br /> ❑ OWNERIOPERATOR ❑ REGIONAL.BOARD COMPANY OR AGENCY NAME <br /> AGENCY p OTHER 454a -j; D <br /> � <br /> [ADDRESS <br /> O-A zip <br /> HONE <br /> a / UNKNOWN <br /> Pyty—ILT PE 4 �Owe: r—l"- i <br /> gADDRESS <br /> W <br /> 2 <br /> crr,. <br /> FACILITY NAME(tF APPLICABLE) OPERATOR PHONE <br /> t ADDRESS <br />- W <br /> arneeT ertY courry <br /> CROSS STREET <br /> LOCAL AGEVCY AGENCY NAME CONTACT PERSON PHONE <br /> zw Em (zoi) <br /> ll;�lp 015k- <br /> La <br /> j L REGIONAL BOARD PHONE <br /> 3 <br /> m (t) NAME OUIINNTITY LOST <br /> UNKNOWN <br /> (2) <br /> Go <br /> L.� Q <br /> z DATE 04SCOVERED HOWDISCOVERED p gNY9iTORY CONTROL p SUBSURFACE MONITOR?q ❑ NUISANCE CONDITIONS <br /> y C3 TAM'MST �ANK REMOVAL p OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> QW j j A A El-W01OWN p REMOVE CONTENTS p CLOSE TANK i REMOVE ❑REPAIR PIPING <br /> HAS BEEN STOPPED Z ❑REPAIR TANK p CLOSE TANK N FILL IN PLACE p CHANGE PROCEDURE <br /> 'FS C] NO IF YES.DATE D t4 REPLACE TANK p OTHER <br /> SOURCE OF ORSCHARGECAUSES) <br /> El TAW TALEAK UNIONOWNN p OVERFILL RE/FAILURE p SPILL <br /> ❑ PIPING LEAK ❑ OTHER p CORROSION UNKNOWN ❑ OTHER <br /> i <br /> W Wa CHECK ONE ONLY <br /> ❑ UNDETERMINED p S00.ONLY p GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w p NO ACTION TAKEN F1PRELIMMARY SITE ASSESSMENT WORKPLAN SUBMITTED 0 POLLUTION CHARACTERIZATION <br /> cc <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY p POST CLEANUP MONITORING IN PROGRESS <br /> w p REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNNECESSARY) 0 CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXC:AVATE i DISPOSE(ED) p REMOVE FREE PROOUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> qee ria�ranm� <br /> o p CAP SITE(CO) ❑ E)=VATE 6 TREAT(ET) ❑ PUMP a TREAT GROUNDWATER(GT)p REPLACE SUPPLY(RS) <br /> Lu <br /> w 0 p CONTAINMENT BARRIER(Cs) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP"A ❑ VENT SON.(VS) <br /> cr p VACUUM EXTRACT No p OTHER(OT) <br /> Lu <br /> Awa as Is" <br />