Laserfiche WebLink
3 -U 0 <br /> UNDERGROUND STORAGI TANK UNAUTHORIZED RELEASE(LEAK) ONTAMINATION SITE REPORT <br /> STATE TE OFFICE OF <br /> c7�AEA EMERGENCY <br /> GENOY SERVICES <br /> O <br /> FOR 'AGENC`L N <> <br /> Rt <br /> LOCAL USE L`� <br /> � BEEN t <br /> REPO FLED <br /> "'li �Ti)ATR <br /> 6 I�iE$If AtiE:ti:QESIGNA60�lf'?!p�lENt'. ••. �JINa>,.... <br /> I❑YES 5 10 ❑YES ��PIO CERT�Y' � EUPtioi'EE Z-:!gt 'H:O <br /> IYI .•. <br /> aeaaIE6:�:THIS:INEaRw►T'lOt'1i.T�:EACAC SECf10rF25rL1CSoF' <br /> REPEAT OATSCASE. <br /> �.! a SNA 3 <br /> e NAME OF INOMDUAL FILING REPORT � PHONESIGNATURE <br /> 0-33L/ <br /> I W REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY <br /> \oaAGEtK,YNAME r j_j.sn <br /> AGENCY ❑ OTHER C t FIC t u l o l <br /> Q ADDRESS <br /> I oe, y <br /> � •Sf Y� GA � a,v sAr <br /> zp <br /> U4 NAME CONTACT PERSONnn PHONE <br /> UNKNOWN q <br /> u1(L ADDRESS <br /> (V pry 0/1lir <br /> f4 Sr►T! � 'D <br /> OPERATOR PHONE <br /> FACILITY NAME(IF APPUCABLEI <br />! ` -; M. U r•cX 1�coi ;, 4e,C{ rr �" �t� )8ZS-3Zz/ <br />! < ADDRESS \\ j at <br /> i 8 p �✓t 1'c��► wr,. S% L 9mp <br /> 53 e v. <br /> H I CROSS STREET -TYPE OF AREA ❑COMMEACXAL❑INDUSTRIAL n❑RURAL TMPE OF BUSPIESS ❑ RETAIL FUEL STATION <br /> ❑REsioe AL � hoo / ALS 4f- ❑ FARM ❑�ER C; <br /> LOICALAGEACY AGENCY NAME CONT PERSON PHONE C <br /> W0' �� s- • i��o � �1: c�L�)y1�33y <br /> z <br /> W REGIONAL30ARO PHONE <br /> it 1 <br /> CVQx-qQ �o �r5 ( ) <br /> (�) NAME OUANTTTY LOST(GMJANS) <br /> Lu <br /> A 1 <br /> Wa 5 0`;✓�t j�UNKNOWN <br /> I ;d (� <br /> Q�UNXNOWN <br /> I z PATE DISCOVEREDI NOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> ?� <br /> w �ul �wl l 0 (YI / Y1 ❑ <br /> TAW TEST �7M0C REMOVAL ❑ OTHER <br /> ~ <br /> DATE DISCHARGEBEGJW METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br />!: s C- Np�OyyN .MOVECONTHiT3 ❑ REPLACE TAW �OSETANK <br /> p HAS OISCHARGE BEEN STOPPED 7 ❑ REPAIR TAW ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p �— YES NO FYES,DATE r 5 n� Y{ 3Y ❑ OTHER <br /> ry SOURCE TANKSCNLYrCAPAC7TY MATERIAL. CAUSEM <br />] � ❑ TANK LEAK �GNKNOWN �•�.Ct�.O GAL ❑ swRmASS ❑ OVERFILL ❑ RIPTURErFALURE <br /> ❑ CORROSION PIPING LEAK AGE 2� YRS !(�STED- ❑ IQ '��"'- <br /> ❑ OTHER ❑ UNKNOWN ❑ SER ❑ SPILL ❑ OTHER <br /> Lu UA CHECK ONE ONLY <br /> v 0. <br /> �I 21�UNDETEAMWED ❑ SOTLON-Y ❑ GROUNDWATER ❑ ORMINGWATER-XNECKONLYFWATERWELLSHAVEACTUALLYB@IAFFeCTEM <br /> CHECK ONE ONLY <br /> t�CESSAFM <br /> t ❑ STTE W VESTIGATION IN PROGRESS(OEFWNG EXTENT OF PROBIFMI ❑ CtfJWIP IN PROGRESS SIGNED OFF(ClFJ1NJP COMPLETED OR U <br /> y ❑ NO ACTION TAKEN ❑ POST CLEANUP MONTTORNG N PROGRESS (❑ NO FUNDS AVAILABLE TO PROCEED �ALUATNG CL.EANLP ALTERNATIVES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(M ❑ EXCAVATE&DISPOSE(EDI ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED Bq pEGRADATION(T77 <br /> �c� ❑ CONTAINMENTBARRi6i(CB) ❑ <br /> EXCAVATE a TREAT(ET) ❑ PUMP 5 TREAT GROUNDWATER(�) ❑ REPLACE SUPPLY(RSI <br /> ❑ TRFATMENTATHOOKUP(MLI ❑ NO ACTION REQUIRED(NW ❑ OTHER(0T1 <br /> W 6 <br /> �/ l/nG Tr'C. nu�ri!r C�cI �L}C7"z// �l C�r1 TarNI'Yt ( h. <br /> p <br /> H9Cas(µan <br />