Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)If CONTAMINATION SITE REPORT' <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL'AGENC'Y USS,QNLT <br /> REPORT BEEN FILED fkER ErVdER1FY7HAS )iAVEDIS...Nj ED THISINFORMAT10NAGC0RDINGTOTli <br /> ❑ YES NO ❑YES ❑ NO <br /> pLStR- ONTHF,IM EETONTHEBACK,pAGEOFTHM. <br /> ISFORhI lJ <br /> REPORT DATE CASE i <br /> :5 3 <br /> I d (IJ DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATU - <br /> 9 <br /> Q REPRESENTING OWNER*PERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAM �..{_c <br /> LOCAL AGENCY ❑ OTHER 6)7 { FV ) <br /> ¢ ADDRESS crrrG/ �CJ� <br /> l �� PHONE <br /> DAME /�•Q�.�(/�,// Q �X CONNTACTPER]S/OONNN <br /> C �^+f��G ❑ UNKNOWNEn <br /> Z cc <br /> r► d <br /> E y ADDRESS <br /> VV y T V 'P 1 [� <br /> Z453 REEY O 0 Cfry SPATE P f`� <br /> FACILITY NAME(IF APPLICABLE) OPEN R PHONE {� <br /> 0 . <br /> f OADDRESS Y(7, c <br /> U <br /> �L7 COW" _ P <br /> w <br /> ui <br /> I CROSS STREET <br /> ('pLcr <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON J PHONE <br /> w C rAJOAl L-� . (� � �6.g o� <br /> z w sus <br /> w U <br /> k w, REGIONAL BOARD PHONE <br /> o 4 <br /> y ft) NAME OUANT[TYLOST(GALLO[VS} <br /> Z> C- CJ ! /�' � <br /> L UNKNOWN <br /> (2)m n (2) <br /> D z UNKNOWN <br /> L z <br /> DATE DISCOVERED HOW DISCOVERED .❑ INVENTORY CONTROL ❑ SU8SURFACE MONITORING ❑ NUISANCE CONDITIONS <br />[ wy Z-., '/ i � <br /> DATE DISCHARGE BEGAN I r ❑ TANK TEST C:3TANK REMOVAL- OTHER c�r �6k 1__ <br /> < wl `� bll i METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m . <br /> NKNOWN ❑REMOVE CONTENTS ❑'CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> Lu y o r <br /> 'n HAS DISCHARGE BEEN STOPPED? tea. %S ❑REPAIR TANK ❑CLOSE TANK 6 FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> a BYES ❑ NO IF YES.DATEo r r ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> Lu <br /> ja ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREfFAILURE ❑ SPILL <br /> Wo ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> ma <br /> < UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKINGWATER •(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w ❑ NO ACTION TAKEN F-1 'PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMIT 11� ❑ POLLUTION CMARACTERIZATION <br /> E7 LEAK BEING CONFIRMED �PRELIMINARY SRE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> v rn ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) _] EXCAVATE a DISPOSE(ED) Q REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> t2iE e�Gt wRnE'�A4W _ <br /> a O ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> LU <br /> Z o ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HUI ❑ +�T SOIL(VS) <br /> 4 VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> W C7`C 0 — Tq CoAJ7AtA j J4J,d(t'L G J Aj � �iD err, AJA� (1ejt/rS'TI C7 A��Y0 rU <br /> s <br /> EurT MAy a� P,45aVIRGD �FvoRC- D A �— �-?►ons Pc41V <br /> 3 G �N g �ref4r,O /A) !2 y � ey Mog 1 <br /> CO s t D �R� D • i�,11 rtJi� <br /> HSC 6S MW <br /> F <br />