Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)1 CONTAMINATION SITE REPORT <br />{ EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL`ACiENCY'USE ONLY. . <br /> ❑ YES NO ED? <br /> REPORT BEEN FIL <br /> ❑ YESNO jHEREeYCERT3FYTHATI HAVE,DfSTRIBUTEDTHi9:& Rl T)ONACCORDINGTOTH <br /> CASE E <br /> REPORT DATE 1BUTE SHOW HE UC NSHEET:ONTHE-$ACKP.AG O THIS <br /> a <br /> M MI s�cNEn <br /> Nso m <br /> AME OF INDIVIDUAL FILINGREE/PO DATE <br /> m ✓ + V� PHONE / CJS SIGN E 'si <br /> Lu REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY R AGENCY NAME <br /> 0 LOCALAGENCY 0 OTHER } <br /> ¢ ADDRESS <br /> 30LIsC-1 STAT 230Z, <br /> wm NAME * <br /> C�ONTACTPERSON Y!P7AHG/O!N1 <br /> 9E <br /> Nz 91 � Q UNKNOWN <br /> d O WAX -S <br /> ADDRESS <br /> rn <br /> tJ <br /> 12, , c0?xlo D 0p <br /> (jv tin srA <br /> FACILITY NAME(IF APPLICABLE) �j����r� OPERATOR <br /> z ` 6 i��.w, ++7�1•,tel �D L7 �[i[►Z/� PHONE <br /> VADDRESSST�/�' <br /> o /SLK/• � ��� ` <br /> F STREET CITY <br /> UNn <br /> CROSS STREET <br /> %A/-I-e <br /> i LOCAL AGEN AGENCY NAME CONT T PERSON PHONE <br /> w vi <br /> CL,a zw <br /> REGIONAL BOAR P ONE <br /> gV <br /> Uw (�) NAME QUANTITY LOST(GALLONS) <br /> H'_ �'rV <br /> UNKNOWN <br /> m z (2) <br /> y <br /> ❑ UNKNOWN <br /> z DATE DISCOVERED HOW pISGOYERED ❑ ,INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> $y + y ❑ TANK TEST ❑ TANK REMOVAL OTHER <br /> w 10.1 3Mi 19"1 <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Li u u b o r yl <br /> UNKNOWN ❑REMOVE CONTENTS I\/I CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> UHAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK 1L}`'�lt CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> En <br /> ❑ YES ❑ NO IF YES,PATE u ul I)i * vv 0 REPLACE TANK F__] OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> c O ❑ PIPING LEAK //❑��OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> Lu wa CHECK ONE ONLY <br /> U ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER 0 DRINKING WATER •(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> i ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> P E7] LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY 0 POST CLEANUP MONITORING W PROGRESS <br /> o ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTIONS) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE TREE PRODUCT(FP) ❑ ENHANCED 810 DEGRADATION(IT) <br /> (ME e K FOR DE A S) <br /> Lu 0❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT]❑ REPLACE SUPPLY(RS) <br /> Lu ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHrR(OT) <br /> z <br /> 0 <br /> U <br /> HSC 05(aW <br />