Laserfiche WebLink
ij <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> I <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 <br /> vEsNo vEs F-1NO1HEREBY CERTIFYTHATI HAVE DISTRIBUTED THIS INFORMATION ACCORDING TOTHE . <br /> DISTRIBUTION SHOWN IXJT <br /> REPORT DATE STRUCTON SHEET ON THE BACK PAGE OFTHIS FORM <br /> ' CASE :/ ` <br /> MI 3 MI d j y _ DATE . <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNA <br /> w E RESENTING COMPANY 10 AGENCY NAME <br /> ❑ OWNERI TOR ❑ REGIONAL BOARD <br /> oLOCAL AGENCY ❑ OTHER t H S it ` /T <br /> ADDRESS <br /> p 0 , altx Q19 �s �K, cq 954467 <br /> STATE ZIP <br /> w N/A/M'EQ JJ I_ p �Q /'' /F� ] [CONTACT <br /> PER/SyO�NT /�D- ,�f / ///� //y� PHONE -/ (} <br /> Z Q li' / � V ` 14 W14S /j ❑ UNKNOWN / \ C..I I I. (,J 1..��"PV 1 / J (p�d� 4f79�5Sl <br /> a a ADDRESS <br /> 6 A3 Rt, c 1 -41 c. a9ve, `Sy4, c - GA `/ 04z7f 6 7 <br /> STREET <br /> STATE <br /> �FFC��'IITy NAME (IF APPLICABLE) pAT <br /> O (f& E PO4 <br /> s m0 µ P� I 79- 5 s s <br /> UADDRESS <br /> (, 3 o tr4c ,` �;` C, hoe'. S�oGK�r� � �� , � dao7 <br /> STREET Glry <br /> CROSS� STREET <br /> � /_ / V <br /> Z LOCAL AGENCY AGENCY NAME CONTACTPERSON <br /> PHONE <br /> w w REGIONAL BOARD <br /> PHONE <br /> NAME QUANTITY LOST (GALLONS) <br /> Z w <br /> F 0 � �— C'1-Q�i. [;oj/UNKNOWN ,I <br /> z_ (2) <br /> a S ✓ U/ / UNKNOWN <br /> Z DATE COVERED (/p /Q HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> M �MI aD of Y� ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> < DATE DISCHARGE BEGAN y METHOD SED TO STOP DISCHAR (CHECK ALL THAT APPLY) <br /> a <br /> Ml M o o y y UNKNOWN EMOVE CONTENTSCLOSE TANK6 REMOVE E::] REPAIR PIPING <br /> 0 HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIR TANK ❑ CLOSE TANK 6 FILL IN PLACE E:] CHANGE PROCEDURE <br /> w00 <br /> o YES ❑ NO IF VES, DATE M M o V ( y �y REPLACE TANK ❑ OTHER <br /> ul W S6URCEOF DISCHARGE CAUSE(S) <br /> fO ❑ TANKLEAK ❑ UNKNOWN OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> OV <br /> PIPING LEAK OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> CHECK ONE ONLY <br /> O Z ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wZ ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ¢ F LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U w ❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE AiCTION(S) EXCAVATE 6 DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (In <br /> do ❑ CAP SITE (CD) EXCAVATES TREAT (ET) ❑ PUMPd TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br /> f < ❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br /> ❑ VACUUM EXTRACT (VE) ❑ OTHER (OT) <br /> f <br /> Z <br /> O <br /> v <br /> HSC m Smm <br />