Laserfiche WebLink
I <br /> 91—uc �� '• <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)!CONTAMINATION SITE REPORT <br /> �.Ij <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERV=5 FOR LOCALAGEN&-' SE ONLY <br /> REPORT BEEN FLED 7 i CF.t, S 1kFa(iMAl7(TrfACxAoiNG raTHE <br /> YES NO YES at i Ft THE 0;gM0rpN Sia ON THE BACX AAc OFTHIS f kE <br /> REPORT GATE CASE r >' <br /> ;:. <br /> �. ,.. A-n <br /> G'.r <br /> �ui wl ,>I : ... .. .....:.... DATE::. <br /> NAME OFwDIVID ALFILINGA FORRTT,�f (PHHOONQAE }NE } S RE <br /> V�f V. r <br /> AEPfiESENTIN OWNFWPERAT•OR K? — <br /> AEGNAL SQARD COMPANY OR AGENCY NAME 3J f C✓ <br /> a ❑ ❑ <br /> LOCAL AGENCY ❑ OTHER �l <br /> t71 <br /> ADDRESS� _ �. r A A.I Z)! ` G srASB <br /> NAME CONTACT PERSON f� PHONE <br /> H Lu W I U 1:1UNKNOWN /CDN V/V lV I�! It z Z-0 <br /> yi ADDRESS I ' <br /> STA•I$ P <br /> FACMM NAME OF APPLICABLE OPERATOR PHONE <br /> a :v W1q ra <br /> < ADDRESS Pf <br /> Aj <br /> 13 <br /> I , <br /> w �04CITY COUNTY P <br /> H CROSS STRQ=T <br /> r� LOCAL AGENCY AGENCY NAME CONTACT PERSON ..� PHONE <br /> w 5.4 �wrirFrf�C�7. pig f�iE�l�!'tF SSS <br /> W a 14- <br /> W wl REGIONAL30ARD - PHONE - <br /> M a <br /> N (I) NAME GUANT(T•YLOST(GALLONS) <br /> LU <br /> �`LSNKNOWN <br /> G 0 <br /> z m �liT� oLLr <br /> UNKNOWN <br /> = DATE DISCOVERED <br /> } HOW DISCOVERED ❑ MENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w_ <br /> Q-' uI _DI D� r ❑ TANK TEST ❑ NK REMOVAL ❑ OTHER <br /> a I DATE OISCNARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> a <br /> W <br /> j uI UNKNOWN [:]REMOVE CONT15NTS Er :OSE TANKS REMOVE ❑REPAIR PIPING <br /> O <br /> HAS DISCHARGE 3EEN STOPPED T ❑REPAIR TANK F:' ❑CLOSE TANK a FILL SN PLACE ❑CHANGE PROCEDURE <br /> H1 <br /> a ❑ YES ❑ NO IEYE3.DATE vt oI rI r ❑REM-AMTANK OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL l,!� RRE(PAILURE ❑ SPILL <br /> U ❑ PIPING LEAK ❑: OTHER ❑ CORROSION UNKNOWN Q OTHER <br /> Lu al CHECK ONE ONLY <br /> ❑ UNOETERM IN® ci�lSOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER;(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AF,--C--E0) <br /> CH;?NO'ACnON <br /> NLY <br /> w � TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMIT TED ❑ POLLUTION CFUIRACTI:RIZATK)N <br /> H ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY i': ❑ POST CLEANUP MONCTORNG IN PROGRESS <br /> U ( ❑ REMEDIATICN PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ m sANUP UNDERWAY <br />_ I i <br /> I CHECK APPROPRIATE ACTIONS) EXCAVATE 3 RISPOSE(EO) REMOVE'F' PRODUCT <br /> ' ❑ ❑ (FP) ❑ ENHANCED HIO OEGRADATION(M <br /> G_zj ❑ CAP SITe(CO) ❑ E)CAVATE E TREAT(E7) �❑ .PUMP S TREAT GROUNDWATER(GT)❑ REM-ACE SUPPLY(FIS) <br /> ¢ ❑ CONTAINMENT BARRIER(CBT ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) rL` <br /> VA Sor L Ff vv'T a' r-,<o,,Lj _iV p l T� 501-L, <br /> 4SS �. iv,G�.- <br />