Laserfiche WebLink
1 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> ❑YES REPORT BEEN FILED? YES ❑ NO GERTiFY.T tAT E AM A:pE$(( ATEQ Ge�VERN I>Ni EMPtaYEE D AT RAVE <br /> REPORTED;T.HlS INFO.iMATION;TO Fp,.M PURSUANT TQ SE0T(ON 2vt8E)7 OF. <br /> CASE i <br /> REPORT DATE SAFtYCdOE <br /> .... ..d* <br /> D1 ly, <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> t <br /> mi \ — <br /> aj'l"- t <br /> REPRESENTING OWNERIOPERATOR ❑ REGIPALBOARD COMPANY OR AGENCY NAME <br /> 0 LOCAL AGENCY ❑ OTHER JA f I'w62 <br /> a,OW46,- <br /> Lu a <br /> cc <br /> ADDRESS <br /> 0Y S. C" stoc4mSTATE Okk ZIP <br /> NAME 7CONTACTPERSON I PHONE <br /> y, ❑ UNKNOWN <br /> a ADDRESS <br /> IXw <br /> L STREET CITY %5705&0STATE <br /> FACILITY NAME(IF APPLICABLE) qu p OPERATOR PHONE <br /> QUU ADDRESS <br /> O <br /> EI' CTTY CaJNTY <br /> CROSS STREET TYPE OF AREA COMMERGIAL❑INDUSTRIAL❑RURAL TYPE OF BU INESS RETAIL FUEL STATK)N <br /> a RESIDENTIAL a OTHER FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w w� REGIONAL BOARD PHONE <br /> CL <br /> N (I) NAME QUANTITY LOST(GALLONS) <br /> ej ❑ UNKNOWN <br /> (2) <br /> n- ❑ UNKNOWN <br /> z DATE DI VERED HQW DISCOVERED ® INVENTORY CONTROL Q SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w TANK TEST � TANK REMOVAL ❑ OTHER <br /> M M D 01 q Y yl x <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M D Y <br /> UNKNOWN REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> W D Y <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p YES ❑ NO IF YES,DATE MI ml D D Y : Y ❑ OTHER <br /> t� SOURCE OF DISCHARGE TANKS ONLYlCAP ITY MATERIAL CAUSE(S) <br /> TANK LEAK UNKNOWN ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FALURE <br /> STEEL CORROSION UNKNOWN <br /> U� ❑ PIPING LEAK AGE YRS ❑ ❑ ❑ <br /> 2 ❑ OTHER C9 UNKNOWN ❑ OTHER F--j SPILL ❑ OTHER <br /> W w CHECK ONE ONLY <br /> 9� ❑ UNDETERMINED E::] SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F- CHECK ONE ONLY <br /> Z <br /> 4 ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS� SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ,❑ NO FUNDS AVAILABLE TO PROCEED ❑ :EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT)° <br /> F*iLa f orcuew <br /> W ke, r w �_ AAhfle <br /> HSc05(40) <br />