Laserfiche WebLink
r <br /> _ D <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES F4fi:EDCA. CAGENCY U5 ONLY <br /> REPORT BEEN FILED 7 <br /> ❑ <br /> YES Na ❑ YES l HEREBY.CE FYT}(AT I HEAVE ISTR16l7TED THIS INFORMATION ACCORDING TO THE <br /> DI I. SHOWN ON TH UCTIaN SHEET.ON THE BACK PAGE:O THIS F M <br /> REPORT DATE///_ (�/J CASE�. /J/� 7 <br /> I <: <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGN%E <br /> Lu REPRESENTING ❑ OWNEWOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> gw LOCAL AGENCY ❑ OTHER <br /> ADDRESS (!`! - CJ `G <br /> 3v � u��� !, S /J. 9f� <br /> ITY STATE <br /> w NAME CONTACT PERSON <br /> PHONE <br /> J T <br />'r z 1 ❑ urlxNrnxNY/ <br /> a a ADDRESS <br /> 3f DD �ra� �n �i `1 �� 2ey� G'19 95�s'F3 <br /> STATE <br /> FACILITY NAME(W APPLICABLE) OPERATOR PHONE <br /> o i <br /> ADDRESS <br /> sD�Lu <br /> G' STREET �a i2�fcy .SII✓ �T� ;, 9s�?� <br /> uy CROSS STREET <br /> AzrllellZ D1211125- <br /> z LOCAL AGENCY AGENC NAME CONTACTPERSON PHONE <br /> w 'T u� �a� blr� <br /> w w REGIONAL 130APIV PHONE <br /> U) <br /> (�) _ NAME QUANTITY LOST;GALLONS) <br /> z w ' �y <br /> Q J ��Sa�f�/t/ UNKNOWN <br /> w <br /> Z (2) <br /> ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lu <br /> /u� u� aI n Q Y� r ❑ TANK TEST [—] TANK REMOVAL OTHER <br /> a DATE DISCHARGE BEdAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Q u M o 0 T UNKNOWN ❑REMOVE CONTENTS 91CLOSE TANK 8 REMOVE ❑REPAIR PIPING <br /> w <br /> vHAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK E::]CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> YES ❑ NO IF YES.DATE �I �/ *ted �Y ❑REPLACE TANK ❑ OTHE R <br /> m.. r <br /> LLJ SOURCE OF DISCHARGE CAUSE(S) <br /> U) <br /> ❑ TANK LEAKK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> 00 ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> a CHECK ONE ONLY <br /> v ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> v ❑ REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 5 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J IgE SICK POR OETAIS7 . <br /> wp ❑ CAP SITE(CO) ❑ EXCAVATE&TREAT(ET} ❑ PUMP 3 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> a ❑ CONTAINMENT BARRIER(CB) NO ACTION REWIRED(NA) ❑ TREATMENT AT HOOKUP fH ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> uj <br /> 0 <br /> O <br /> U <br /> HSC 05189% <br />