Laserfiche WebLink
i <br /> UNDERGROUNTOME TANK THORIZED RELEASE (LEAK)l CONTAMINATION SITE REPORT <br /> EMERGENCY ASSrarEOEFICE EMERGE sERVICES FOR ILO 'AGENCY USEONLY:; <br /> O YES ��NO <br /> REPORT BEEN FILED? El YES �NO ]'HERE ERTIFY THAT:I AM OES] TED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPO THISr:INFORMATI TO A[-OFFICIALS.-PURSUANTi',TO:SECTfON 25f80:7.OF <br /> REPORTDATE <br /> CASES THE ANDS Y <br /> r' <br /> MIL AI , O Y Y SIG TE <br /> N E OF INQIVIDUAL FILING REPORT PHONE p = I; SIGN RE <br /> (M) Y'.'g f <br /> D REPRESENTING O OWNERIOPERATOR Q REGIONALBOARD COMPANY OR AGENqY NAME <br /> p Ej�i<OCALAGENCY 0 OTHER S C• `., �f`�•.r <br /> ¢ ADDRESS I <br /> e� 7� n 31 <br /> U Y 1 C iJ d <br /> 1.' ' c r��� � II: r 1 Ztp <br /> ( �7 STREET <br /> NAME �y��� CONTACTPERSON�I PHONE- <br /> 9D y� !/l-L'4i UNKNOWN ` It.LJ� �� Lk?') G <br /> ¢ <br /> a ADDRESSLu <br /> j 7 L 1 <br /> ¢ C� <br /> TFEET Is CffY' r SPATE II= ''ZIP 6 <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE I, <br /> ADDRESS <br /> i. . <br /> O L'AL b 6kl E�� tid �Y CRYIFLic 4°C.f � COUNTY . I� p �II <br /> NCRQSS STREEPT TYPE OF AREA COMMERCIAL 'Q INDUSTRIAL Q RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> 0 RESIDENTIAL OTHER pF FARM Q OTHER G' kI <br /> I <br /> `ryt6CALAtElICY AGENCY NAME CONTACT PERSON., PHONELu <br /> > <br /> w REGIO BOARD PHONE <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> LU <br /> 0 �(/1+�J q ' ii! dUNKNOWN i <br /> (2) + i <br /> UNKNOWN <br /> r �D�A�}TE DISSCCOVERfED l (y HOW DISCOVEREO �� INVENTORY CONTROL i � SUBSURFACE MONITORING i � "NUISANCE CONDITIONS <br /> 4 M v u ` P ` o O v r 0 TANK TEST �TANK REMOVAL, ';0 OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY)!, II x <br /> 1 <br /> © UNKNOWN Q REMOVE CONTENTS REPLACE TANK OSE TANK <br /> HAS DISCHARGE BEEN STOPPED 7 :� REPAIR TANK RE AiR PIPING 0 CHANGE PROCEDURE ) <br /> NO IF YES,DATE 0. o- p �Y Y ❑ ,OTHER :. ` i J. <br /> } <br /> SOURCE OF DISCHARGE TANKS ONLYSAPACITY MATERIAL CAUSE(S) " <br /> E] TANK LEAK �UNKNOWN S S GAL. �{FIBERGLASS E] OVCRF1LiL � RUPTURF�FAILURE k <br /> ¢ ❑ PIPING LEAK AGE YRS �'STEEL CORROSION UNKNOWN ) <br /> OTHER UNKNOWN ❑ OTHER: .€ SPILL ❑;.OTHER I <br /> Lu w CHECK ONE ONLY i <br /> v Z UNDETERMINED 0 SOIL ONLY Q GROUNDWATER E] DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY T <br /> i' <br /> mW SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) E] CLEANUP IN PROGRESS Q SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ¢ <br /> - p iV :; il� i <br /> V <br /> La NO ACTION TAKEN O POST CLEANUP MONITORING IN PROGRESS NO FUNDS AVAILABLE TO PROCEED 0 EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR TAILS) F <br /> z CAP SITE(CO) EXCAVATE d DISPOSE{ED) 0 REMOVE FREE PRODUCT(FP) � ENHANCED BIO DEGRADATION(IT) <br /> 0 CONTAINMENT BARRIER(CB) PEI,EXCAVATE d TREAT(ET) <br /> PUMP 6'TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> i ! <br /> Lu <br /> ¢ Q TREATMENT AT HOOKUP(HU) Q NO ACTION REQUIRED(NA) OTHER{OT} <br /> py <br /> HSC 0514A7F <br /> � I F <br />