Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCYUSE ONLY:: <br /> ❑ YES NO REPORT BEEN FILED? ❑YES NO I:HEREBY CERTIFY.T 1 AMA,0 TED GOVERNMENT EMPLOYEE AND THAT 1 HAVE <br /> REPORTED THIS I OR TI AL OFFICW.S>PURSUANT TO.SECTION MO.?OF <br /> REPORT DATE CASE# THE HEALTH AND <br /> M� 1M o l Dl a r r SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> > �qv�d Cams (2oa) Y6rr -Syyo <br /> m <br /> w REPRESENTINGOWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME } <br /> p LOCAL AGENCY OTHER Spy�.. �O o� i•. cam►I NPs ���+ S�V c 1 <br /> Q_ <br /> Wr ADDRESS <br /> S><'HEET CRY STATE ZIP <br /> NAME CONTACT11PERSONT PHO�N`E <br /> z¢ 1� �VS�•o�.t✓ C. ❑ UNKNOWN �oK� vO�KSo� <br /> Ra ADDRESS <br /> N <br /> yNs P� � ad. <br /> STREET 4=�CRYy <br /> STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> Q <br /> t ADDRESStglytjj <br /> w STREET CRY COUNTY Ip <br /> in CROSS STREET TYPE OF AREA X COMMERCIAL a INDUSTRIAL a RURAL TYPE OF BUSINESS E:] RETAIL FUEL STATION <br /> RESIDENTIAL a OTHER a FARM a OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> �e� lth +S{d;�l �avTd Ga��s (Z�o() yroF-344o <br /> w REGIONAL BOAR PHONE <br /> a R q <br /> C'L-'i'a 1 1 �-A 2 O✓ `J o S ( 1��r ) (o - 0 00 <br /> u) (t) NAME QUANTITY LOST(GALLONS) <br /> w p <br /> Q UNKNOWN <br /> 0 (z) <br /> UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w <br /> OM 3 M Op 3 p a-y � J ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Mw <br /> M 0 0 v y UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> 0 HAS DISCHARGE BEEN STOPPED? F-1REPAIR TANK ❑ REPAIR PIPING ElCHANGE PROCEDURE <br /> p ❑ YES ❑ NO IFYES,DATE MI M D o Y y ❑ OTHER <br /> N SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK X UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RLIPTUREFAILURE <br /> ❑ PIPING LEAK AGE YRS ❑ STEEL ❑ CORROSION N--'r UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL a OTHER <br /> Lu wa CHECK ONE ONLY <br /> o ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> AJ <br /> F CHECK ONE ONLY <br /> z� <br /> s ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> c� <br /> U H NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> r <br /> 6 ❑ CAP SITE(CO) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) a EXCAVATES TREAT(ET) ❑ PUMPS TREAT GROUNDWATER(GT) a REPLACE SUPPLY(RS) <br /> ❑ <br /> TREATMENT AT HOOKUP(I" ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> to �!ow�C�wa+G✓' co„A-F'p�,l,,,.i 1.��-�:.�. ttio-`�d cLu✓l ��F V'C_'t.JV 11. tO V J.....c� w��!✓` �o..... , <br /> F- c <br /> A+ }r <br /> HSC O5(4M7) <br />