Laserfiche WebLink
g� Dl <br /> --------------- <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY BE FDRtOCA�+IGENCxUSEOIAY7777777777T== <br /> ❑ <br /> YES NO REPORTBEEN FiLEDT ❑YES NO 1HEf BYa[p1JFYTW�( iIB11VHDLS�TRIBt1TEDTHIS YFDRMATAf1.ABC0RDW0TOTN£ <br /> REPORT DATE CASE I. 4WTFM ON7TIE6ACR PAi;EOFTHSFbRM. <br /> / I <br /> N4 201 1021 <br /> M <br /> NAME Of INCWIDUMIL FILING T BgNEd DATE <br /> m C=+ A•T kc pA) <br /> REPRESENTING ❑ OWNEIVOPERATOR ❑ REGIONNLSOARD COMPANY OR AGENCY NAME <br /> AGENCY ❑ sTG P tI�l ETu <br /> 30q E We.�o er' Ave;-TK' rd Rbc- <br /> NAME <br /> dIATI <br /> 1 CONTACT PERSON PHONE <br /> ' <br /> N o NADDRESS et d (51a) 336 <br /> FACILITY NAME IF APPLICABLE) 6lA1!OPERATOR PIDNE <br /> S(a ( ) <br /> ADDRESS Q52EXp (Z) <br /> CAMSTam <br /> LOCALABENCY AGENCY NAME CONTACTPERSON <br /> 1G Pt4s etF� U PHONE <br /> (2�f1)qbfyA ' -lI <br /> SGK)NAL BOARD <br /> GV C 'evC raj Ua k 6e4-k 2r` (9 );55- <br /> m (AI NAME v QUANTITY LOST AALLONS) <br /> 1 tl2 <br /> UNKNOWN <br /> ❑ <br /> DATEolacovERED HOW DISCOVERED ❑ INVENTORYCONTRa F] SUBSURFACE MONITORING E] NUISANCE coNDITDNa <br /> W TANKTEST TANK REMOVAL ❑ OTHER <br /> D r ❑ <br /> DAYS DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(ORIECK ALL THAT APPLY) <br /> a[ ul ul j d AmUNIONOWN ❑REMOVE CONTENTSIeCLOSE TANK B REMOVE ❑REPAIR PIPING <br /> NAS OMMVIAGE SEEN STOPPED T ❑REPAIR TANK ❑CLOSE TANK f FILL IN PLACE ❑CHANGE PROCEDURE <br /> 7ffiS - YES.❑ NO IF YES.DATE Y Y ❑REPLACE TANK ❑OTHER <br /> G OF D18pMRC� (S) { <br /> ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTUREFAILURE ❑ SPILL !i <br /> ❑ PIPING LEAK ❑ OTHER ❑ CORROSION - UNKNOWN ❑ OTHER 1 <br /> mm CHECKONEONLY <br /> UNDETERMINED ❑ SOLONLY ❑ GROUNDWATER ❑ DRINKING WATER-(CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CFECKONEON-Y <br /> ❑ NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMTRRD ❑ POLLUTION CHARACTERRATDN <br /> ❑ LEAK BEm CONFIRMED "� PRELvAKw SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> 0 REMEDBITIDN PIAN ❑ CASE CLOSED(CLE~ODMPLETEDOR UNNECESSARY ❑ CLEANUP UNDERWAY <br /> GiCKAPPROPRNTE ACTION(S) E)rAVATE A ONSPOSE <br /> IeMs�imma�q (EO) ❑ REMOVE FREE PRODUCT(FP) ❑ ENiANCEDBIOOEGRADATDNn <br /> 8Tc ❑ cAPartE ICD) ❑ E)DAVATEATREAT(ET) ❑ PUMP&TREAT GROUNDWATER(QT) REPLACE SUPPLY IRS) <br /> g ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTIN REGUIRED INA) ❑ TREATMENT AT HOOKUP(NH ❑ VENT SOIL(VD ` <br /> ❑ VACUUM EXTRACT(VE) ❑ On"ron <br /> Sl2 ( C2� ITS - �OCa-Q ovkP,"lpfd M <br /> a�e�eM,ewE- &e;kQf wlne -%bare, axil c.�ewd' ofdtc1 el, <br /> x <br />