Laserfiche WebLink
`� • u,z5 <br /> UNDERGROUND STORAGE TA K UNAUTHORIZED RELEASE(LEAK)/C TAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES .fOR LQGAt.AGENCY;USE; Nk Y. <br /> REPORT BEEN FILED? <br /> Ej YES No ®YES' 1t1tREBY CERT)FYTkiA?i HAVE AISTRIBUTED THIS(NFiMA AC OtNG TOTHE; <br /> ,O! T N; TH IN UCTION SHEET ON THE K FAG THIS. <br /> REPORT DATE' CASE <br /> mi M Y SKsNE6 DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> C'I ) y <br /> Lu REPRESENTIN ® OWNERlOP TOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> cr <br /> LOCALAGENCY � OTHER F-Pig: <br /> ¢ ADDRESS <br /> e <br /> STREET CITY STATE ZIP <br /> J NAME CONTACT PERSON [PHONE �+ <br /> z d $ ❑UNK N <br /> rkel <br /> (L a ADDRESS <br /> W c <br /> EET My STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> [I'-- C ( } <br /> ADDRESS <br /> STREET CITY COUNTY ZIP <br /> CROSS STREE <br /> O LOCALAGE CY AGENO NAME CONTACT PERSON PHONE <br /> po <br /> w REGIONAL BO RD P E <br /> 2e A- ( ) <br /> U) (1) NAME QUANTITY LOST(GALLONS) <br /> LU Cl <br /> z®❑ UNKNOWN <br /> ca <br /> ❑ UNKNOWN <br /> 1— DATE DISCOVERED HOW DISCOVERED: ® INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 6.1 M1 [,Io YI Y ❑ TANK TEST TANK REMOVAL ❑ OTHER • <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> cc j a <br /> UNKNOWN ❑REMOVE CONTENTS LOSE TANKB REMOVE ❑`REPAIR PIPING <br /> M o Y <br /> p HAS DISCHARGE BEEN STOPPED? �❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> ES ❑ NO IF YES,DATE M Y ❑REPLACE TANK ❑OTHER <br /> S RCE OF DISCHARGE CAUSE(S) <br /> Q= ❑ TANK LEAK UNKNOWN ® OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> � <br /> u ❑`PIPING LEAK Zo OTHER E] CORROSION NKNOWN F OTHER <br /> m a CHECK ONE ONLY <br /> V NDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER-(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED)'' <br /> ECK ONE ONLY <br /> z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> s <br /> =N <br /> O ❑ LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> ISEE WK FM WTMAJ <br /> `tF3 0z ❑ CAP 817E(CD) ® EXCAVATE 8 TREAT(ET) ❑ PUMP 8 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Lu <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA)' ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> ct 0Sl c <br /> z 44NR <br /> e- Y' c m O <br /> eSU <br /> HSC 05(&W <br />