Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES 'FOR LOCALAGENCY:USE,ONLY <br /> Y ERtJ�AE(+fT EMPI.OYEE'AND THAI i HAVE <br /> ❑YES C,] REPORT BEEN FILED? <br /> ❑ ES NOENO <br /> THt51 >T3iAT I AM11 DESIGRATED GOVS-$B-L �E� A_NT TO SECTION 2S1B0.7 OF <br /> REPORTOATE CASES <br /> FTHEH <br /> J <br /> 0 vi I NEO.. r>: <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> 4 - f6 <br /> o REPRESENTING ❑ OWNER+OPERATOR ❑ REGIONAL BOARD I 0OMPANYORAGENbYWQE <br /> LOCAL AGENCY OTHER <br /> w <br /> cc ADOROS <br /> STREET CITY _ STATE ZIP <br /> NAME CONTACTPERSON PHONE <br /> y� A1)n Gt��C� UNKNOWN f ) <br /> fn <br /> a ADDRESS l � G� �V P <br /> w I <br /> Q <br /> Y CT' 3CATE P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR /PHONE <br /> ADDRESS <br /> f ) <br /> 37R£ CITY GOU <br /> yCROSS STREET TYPE OF AREA ❑COMMERCIAL Q INDUSTRIAL RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> p ❑RESIDENTIAL ❑OTHER ❑ FARM OTHER <br /> LOCAL AGENCY NAME CONTACT PERSON PHONE <br /> Lu cv <br /> REGIONAL HOARD rPHON <br /> _��� i � NAME dilIWTRY LOST{ <br /> C/y/�/' �\ UNKNOWN <br /> (2 <br /> ' ❑ UNKNOWN n <br /> z //DATE DISCO VEREO HDWDISGOVEREO INVENFORYCONTROL Q SUBSURFACE MONITORING Q NUMANCECONDfTIDNS WV <br /> LlI� Mt-5.16o17 r v ❑ TANK TEST TANK REMOVAL ❑ OTHER ` <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> t <br /> w M u o c v UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? REPAIR TANK ❑ REPAIR PiPM ❑ CHANGE PROCEDURE <br /> S Q YES ❑ NO FYES,DATE ml oI 01 Y1 Y ❑ OTHER <br /> u� SOURCE OF DISCHARGE TANKS ONLY,CAPACITY MATERIAL CAUSES) <br /> a ❑ TANK LEAK FUNKNOWN BOO GAL �Q} FIBERGLASS ❑ OVERFILL Q RUPTURElFAILURE <br /> FlPIPINGLEAK AGE YRS STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ 07 <br /> CHECK ONE ONLY <br /> ❑ UNDETERMINED CWSCILONLY GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> z� <br /> Q ❑ SITE INVESTI3ATION IN PROGRESS(DEFINMG EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> H ❑ NO ACTK)N TAKEN ❑ POST CLEANUP moNTTORING iN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CO) EXCAVATE 6 DISPOSE(£D) � REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(C8) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) Ej REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(NU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> �� ,P 1v��'S o —i4 12F�yvvgL , )0 <br /> ev [7'�4A-r�'nL4T.rr�nJ, Fv,4I' "'j �+ci�l'T /�1 <br /> rr�' <br /> "Co5{"m <br />