Laserfiche WebLink
0 41 oo - u.oI <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 4 j HEREBY CERTIFYTkfAT(HAVE DISTRIBUTED THIS INFORMATION ACCORDING TOT HE <br /> ❑ YES NO ❑ YES NO <br /> :01STRIBUT(ON SHOWN ON THE INSTRUCTION SHEET.ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE CASE ae <br /> M ml dv ,518NED DATE '; <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIG <br /> ami c� 5G' (— `� ) �'{ <br /> w REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> cc <br /> LOCAL AGENCY ❑ OTHER G' 4 J 0 e�j <br /> ¢ ADDRESS 61 <br /> STREET CITY STATE ZIP <br /> NAME CONTACT PERSON PHONE <br /> J rg <br /> ZQ Y (� I UNKNOWN �1fAw <br /> a< ADDRESS <br /> Li <br /> ' 4;0 o _ E <br /> RESTY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATORPHONE <br /> al <br /> ) us l <br /> ADDRESS _ <br /> r7o <br /> w STREET CITY COUNTY 21P <br /> Di CROSS STREET <br /> O LOCAL AGENCY AGENCY NAME CONTACT P RSON PHONE <br /> z ev <br /> w w <br /> REGIONALBCAD PHONE <br /> LU (1) I NAME OUANTITY LOST;�; <br /> S) <br /> W c/a,o 1fKNOWN <br /> m z (Z) <br /> 1 UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ 1 VENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONSui I <br /> w MI MI D y y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHA E(CHECK ALL THAT APPLY) <br /> m <br /> 2UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> w M M d D Y Y <br /> p HAS DISC RGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o YES ❑ NO .IF YES,DATE /M MI o D v v REPLACE TANK OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> cr a ❑ TANK LEAK UNKNOWN F--] OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> N U ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> ti nw CHECK ON ONLY <br /> U UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Lu <br /> Z NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> Q <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) 0 XCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> Q Z ISEE BACK FM DETAM <br /> Lu <br /> 0 ❑ CAP SITE(CD) EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTON REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> a: ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> w <br /> w <br /> 0 <br /> 0 <br /> U <br /> HSC 05(Mq <br />