Laserfiche WebLink
V <br /> UNDERGROUND STORAGE TANK UNAUTHORI AS (LEA I C N AMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY:,USE ONLY <br /> 4 REPORT BEEN FILED? I HEREBY CERTIFY-THAT E AM A DESIGNATtb GOVERNMENT EMPLOYEE RNR THA7<1 HAVE: <br /> ❑ YES NO ❑ YESDEPORTED:'fH15 INFORMAT)CN TO O AL OFF).. .. PURSUANT TO SECTION 251807 .Of <br /> REPORT DATE CASE <br /> THE HEALTH MD SAFTY E <br /> SIGNED „1: <br /> pp��++'� C 1` 4 <br /> �./!e� � IY !l v � <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> w REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONALBOARD COµPANYORAGENCY NAME <br /> cc LOCAL AGENCY OTHER <br /> CL <br /> I <br /> Q ADDRESS ?;,49sTReFrSTATE ZIP <br /> NAME CONTACTPERSON PHONE <br /> i ( rGi ❑ UNKNOWN f C C.'-e/ liG l 76 <br /> ga ADDRESSLu <br /> Q /f n(/ <br /> cc -� t �� '�'fiiEET�� �-�G�' STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) f OPERATOR PHONE <br /> Q n r �i'Orz C i ? -� 7b <br /> UO4 ADDRESS(`7(�} <br /> U r - STREET J vv CRYCOUNTY <br /> y CROSS ST TYPE OF AREA COMM CIAL INDUSTRIAL❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> {�/` ❑RESIDENTIAL ❑OTHER ❑ FARM II�YVI/OTHER <br /> LOOCA`,L�AGSNCYY Y i AGENCY NAME p CONTACT PERSON y Jp PHONE <br /> C� <br /> A. �1 c9� JT✓t Lc rliv av1 � ✓IIJ� ! j1 3� PHONE�1 �7�� <br /> J REGIdNAL HOARD <br /> CL <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> LULLJ / , ^ <br /> CSS _I/ UNKNOWN ~. <br /> ~O (2) <br /> �n-Z-4c Vic <br /> UNKNOWN <br /> i DATE DISCOVERED NOW OLSCOVERED ❑ INVENT04Y CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDrnONS <br /> G rte. <br /> Lu ❑ TANKTEST TANK REMOVAL ❑ OTHER <br /> r M 0 KC <br /> Y Y . <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN 0 RZ MOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> Q M I M 01 D Y Y <br /> y ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> HAS DISCHARGE BEEN STOPPED 7 <br /> 3sroYES ❑ NO IF YES.DATE ❑ OTHER <br /> y SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> TANK LEAK ❑ UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL >rRUPTURF�FAILURE <br /> 0 PIPING LEAK AGE YRS PK�STEEL ❑ CORROSION ❑ UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> f w W CHECK ONE ONLY <br /> a <br /> U it: 26 <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKONEONLY <br /> zm <br /> E �a � SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) E-1CLEANUPIN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> c� <br /> L) n ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑.r EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> z ❑ CAP SITE(CO) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ .ENHANCED BIO OEGRADATnN(IT) <br /> 43 g <br />' w ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) E:] PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(AS) <br /> cc <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTON REQUIRED(NA) ,OTHER(OT)_A) <br /> t <br /> 1,k), � r <br /> MSC 051u67) <br />