Laserfiche WebLink
i <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> f+AFRGfNCY I{AS STATE OFFICE OF EMERGENCY SERV' :'€13Fi LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 tF1ERE8YCEIXTIFY.. HAVE.DISTq�UFEDTHI51NFbFtMAT�DNACObRDINGTOTHE �5 <br /> YEs YES NO ',DIS#F3l6UTl UC7iDNSkEEf'ONTHEBACKf H QAM <br /> --..-.r <br /> REPORT PATE CASE 0- <br /> C <br /> • <br /> � r <br /> 0.1 M1 O :SIGNED :4ATE <br /> NAME 4F INpIViDUAt FILI REPORT PHONE SICNAIlJRE <br /> d REPRESENTING REGIONAL BOARD .. <br /> ( Q OWNEA/C7PERATDR COMPANY OR AGENCY NAME <br /> Q <br /> Q OCALAGENCY OTHER r"?�' ,� �^'�• � 7R' <br /> a <br /> ADDRESS ! L71� (�►� 1�'5'-- 5"72 /',ok7&A /A_.. 'F6�Q a <br /> STREET GTT`I HTATF ZIP <br /> w NAME CONTACT <br /> PERSON p�// GA�.]� /PHONE <br /> m �/tll� �� ���r 1 O UNKNOWN <br /> ADDRESS <br /> AID <br /> STREET GRT' STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> U ADDRESS /�-� � �Uf�.�• '` �/ -S 4 <br /> ."4�l � <br /> QAJ STREET crrY COUNTY zip <br /> Ui CROSS STREET <br /> V LOCAL AGENCY AGENCY NAME CONTACT PERSON '1 PHONE <br /> �f�S�y� �/G —i V�—v 3.33 <br /> uj <br /> RFGIONAL BOARD - PHONE <br /> w (I) NAME OUANTfTYLOST(GALLON y <br /> uj <br /> UNKNOWN <br /> a� <br /> T (2) <br /> y <br /> UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED NDITIONS <br /> ;. <br /> O INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CO <br /> U,d n Y 2, a TANK TEST TANK REMOVAL t <br /> ;OTHER <br /> DATE DISCHARGE BEGAN 7 METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) ) <br /> 1F l d O Y ®UNKNOWN RCMOVE CONTENTS CLOSE TANK A REMOVE 0 REPAIR PEPING <br /> w <br /> U HAS DISCHARGE BEEN STOPPED 7 0 REPAIR TANK CLOSE TANK 8 FLL IN PLACE CHANGE PROCEDURE <br /> 25YES D NO IF YES,DATE IA n Y- Y o REPLACE TANK 0 OTHER <br /> I <br /> SOURCE OF DISCHARGE CAUSES) <br /> ¢ TANK LEAK ` UNKNOWN OVERFILL� I � RU TUREIFALURIE � 0 SPILL <br /> v PIPING LEAK 0 OTHER CORROSION UNKNOWN a OTHER <br /> vi i� CHECK ONE ONLY <br /> UNDETERMINED 0 SOIL ONLY GROUNDWATER [:] DRINKING WATER .{CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED ' <br /> I <br /> CHECK ONE ONLY , <br /> u,U) O NO ACTION TAKEN .o PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> U) <br /> j w O LEAK BEING CONFIRMED a PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(5) Q EXCAVATES DISPOSE(ED) ED REMOVE FREODUCT(FPS E] ENHANCED 810 DEGRADATIQN A <br /> OU b%0K FM 6ETAM E PR ',. <br /> 5 Q CAP SITE(CD) EXCAVATE 8 TREAT(ET) o PUMPS TREAT GROUNDWATER(GT) REPLACE SUPPLY{RS) <br /> w <br /> Lu <br /> a - 0 CONTAINMENT BARRIER(CB) _ NO ACTION gEOUIRED(NA) TREATMENT AT HOOKUP(Hli) VENT SOL(VS) h <br /> O VACUUM EXTRACT(VE) i OTHER(OT) F t' <br /> moi l it -7PVAI . <br /> -i*1A%�/ iv.`/ 'n <br /> HSC C6 W" - <br /> Y • <br />