Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> £MFRGFNGY HAS STATE OFFICE OF EMERGENCY SERVICES OR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 71 HEREBY CERTIFY ISI 15 INFORMATION ACCORDING TOTHE <br /> { ] YES_ NO DYES pISTRIB HS WSTRUCR T HEET ON'Me BACK PAGE OF THIS FORM <br /> RC PORT DATE <br /> CASE. <br /> 0. � 2 Eo DATE <br /> NAME OF INOIV UAL F LIN PORT PHONE SIGNA <br /> 39 <br /> L1 �. <br /> RFPnFSEN G ❑ OWNER/OPERATOR ❑ REGIONAt BOARD COMPANY OAR A-_G+E^NC�Y NAME <br /> LOCAL AGENCY ❑ OTHER �/4 CO- Pr�S <br /> IF ADDRESS <br /> STREET /Y 4J r / r •J CIT`I - STATE ZIP <br /> to cl <br /> NAME CONTACT PERSON PHONE <br /> y /t( L�l�vs /� UNKNOWN Q� V,1� �� ) a4 <br /> 0;� nooREss <br /> Q G4D <br /> w O �--- <br /> STREET CITU STATE I <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> c ADF,Rs=SS �, <br /> �'/D <br /> w STREET CRY COUNTY IP <br /> N CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON J PHONE <br /> u <br /> RFCIONAL BOARD PHONE <br /> .t7 <br /> a. a <br /> 2 <br /> (I) NAME QUANTITY LOST(GALLONS) <br /> 0 E�NKNOWN <br /> a ' _ <br /> m 7, <br /> n ❑ UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS \n <br /> z �J <br /> w Qw� ra o YJ <br /> v ❑ TANK TEST F?J�TANK REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BI GAN METHOD USED TO STOP DISCHARG (CHECK ALL THAT APPLY) <br /> 4_wl tI D� v v NKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE a REPAIR PIPING <br /> LLJ o HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK R FILL IN PLACE ❑CHANGE PROCEDURE <br /> YES ❑ NO IF YES,DATE 'I 'I <br /> yl v ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> a 7 TANK LEAK ET UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE O SPILL <br /> O L- PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w CHECK ONE ONLY <br /> V)(L r <br /> F-] UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHFCK ONE ONLY <br /> �� A ❑ NO ACTION TAKEN ►❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ul T� <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> v � <br /> ❑ REMEp1AT1DN PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) � CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATES DISPOSE(ED) ❑ REMOYE FREE PRODUCT(FP) © ENHANCED BIO DEGRADATION(IT) <br /> 1�ew«ac raR eEtual <br /> zPUMP 4 TREAT GROUNDWATER{GT) REPLACE SUPPLY(RS) <br /> ca U ❑ CAP SITE(CD) ❑ EXCAVATE A TREAT(ET) ❑ ❑ <br /> wt' VENT SOIL(VS) <br /> 3 a 0 CONTAINMENT BARRIER(CB) E] NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ <br /> LJ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> fn <br /> � <br /> sr�'EFiu.4 <br /> HSC 0516'901 <br />