Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (Ii EAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY VICES FOp!dCAi AGENCY USF.ONLY, <br /> ❑ YES ❑ NO REPORT BEEN FILED 7 - <br /> f ES ❑ NO IHEiiEBY.CERTIFYTHATI}{A1!EDISTRI9q'T'FDIS,INFORMA710NACGUFtDINGT <br /> CASE;1 OTHE <br /> ff REPORT DATE DI5TR18UT#pN SHOWN DN THE INSTRUCTION SHEET ON 7}{E:BgCK PAGE.QF 7NIS,FQAM <br /> Y SGHE6sm <br /> NAME OF INDIVIDUAL FILING'REPORT PHONE GATE^ <br /> II SIGNATURE <br /> i 1 toI q0 a _ <br /> I 6 , <br /> r REPRESENTING <br /> l WNEFUOPERATOR ❑ .REGIONAL$OARD CO PANY OR AGENCY NA <br /> ❑ <br /> 1 LOCAL AGENCY THERwi Fr, ` ,J rpr <br /> ADDRESS R D ` 0 oG�jYL <br /> STREET r ��,. I�� A �-`. C� <br /> w NAME 0r w STATE <br /> P <br /> ca ray <br /> � �1�./`- DTVI CONTACT PERSON rF -PHONE <br /> z ❑ UNKNOWN r rI ` N !3{� Com/ �•� J <br /> ADDRESS 0 I <br /> cc © fox �o0 38 r� ' ;, r " q Loa - 6o Sep <br /> =L - r <br /> s�_. <br /> FACILITY NAME(IF�iCABLE) sTAP ZIP <br /> 7/V11 OPERATOR PHONE <br /> on. <br /> c A DRESS <br /> rM m' 23' <br /> 1(o I W. flaw, Ater Law? 360T <br /> f STREET <br /> CROSS 53REEk courm ZIP <br /> D L AL AGENCY AGEN Y NAME <br /> z CONTACT PERSON O� PHONE <br /> W O OCA- 2a j QIvrlPN ,a <br /> ww REGIONALB A r`"Q� q <br /> a PHONE t. ffE <br /> iNAME f <br /> LU <br /> W () QUANTITY OST((3�k0►�} <br /> h d (+ I G! N <br /> ILm <br /> (2} <br /> m ; <br /> �- DATE DISCOVERED HOW DISCOVERED F0 47KNO& <br /> Lu ❑ INVENTORY CONTROL ❑ SU L3RFA E MONI ORING ❑ NUIS TONS s <br /> F .0 al v y ❑ TANK TEST ❑ TANK REMOVAL OTHER r-0 <br /> DATE SCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT AP LY) <br /> f <br /> � u 31µ p <br /> C2,,l 13,1 ❑ UNKNOWN El REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PG <br /> p HAS DISCHARGE BEEN STOPPED? <br /> U ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PAOCEDURE,. <br /> ' <br /> ES NO IF YES,DATE <br /> >7 ❑ I ( n p Y Y ❑REPLACE TANK :I ❑ ETHER <br /> SOURCE OF DISCHARGE CAUSE(S) o tq m C-pop rL• Q Y'G� /Q�'© <br /> j¢ ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE SPILL !I!l��N a Ib l_r�Vl <br /> U ❑ P3PING LEAK F-] OTHER ❑ CORROSION UNKNOWN OTHER 1 <br /> Lu a CHECK ONE ONLY I, <br /> U ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER ="(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY a <br /> w ❑ NO ACTION TAKEN- ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> N ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MON3TOAING IN PROGRESS <br /> U <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> EI j; <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 8 DIS (ED) ❑ REMOVE FREE PROQUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> t4[ <br /> no ❑ GAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP a TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(AS) <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑�AREQ IR D(NA) ❑ TRE TMEN7 ATH KUP(HU) ❑ VENT OlL❑ VACUUM EXTRACT(VE) ++ <br /> G��. Cos" h c' o s 0 e__� rro aeu. f va a .Lt <br /> w A e_ as t f <br /> �. ►4 <br /> � �a ►� t k. Q., v-©cess o <br /> D <br /> c� Ire rM a Oct Q ea rs <br /> h e.cerS3 Q Y- rR e N a r l q �' . Nsc 0("', <br /> 4 <br /> v bej <br /> i �t <br />