Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL'AGENCYIUSE ONLY <br /> ❑ REPORT BEEN FILED ❑YES NO 1HERESYCEHtlFYTHATI.HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> VES NO <br /> REPORT DATE DISTRIRUTIONIHE INSTAUCTK)N SHEET ON THE BACK PAGE OFT SFORM <br /> M a / `" I yDATE <br /> g�jGp� <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNA E F <br /> w REPREBENTI ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCYN ME <br /> O LOCAL AGENCY ❑ OTHEfl �A4 - /s-.vf_ <br /> ¢ ADDRESS ' ^Y K N!f <br /> W/K AJ s14,T! cTovieP=q/ srr <br /> s neE Cm <br /> 4AE <br /> m NAME /' CBONTACTPERSON�A` 'rte PHONE 210 'l <br /> pd L .I�1lL� ❑ UNKNOWN <br /> No ADDRESS <br /> C. <br /> ¢ Zdvv �TG�r4NE�E' f-ogj G�JZZ2 � �5uf� <br /> STREET <br /> FACILITY NAME(IF APPLICABLE) cm <br /> OPERATOR SATS v <br /> Z F�G (PHONE 1 <br /> a ADDRESS <br /> w Qir� �v ttlFa°�STREU <br /> ; ZIP <br /> ROSS STREET Crty LOUNir' ZIP <br /> i LOCAL AAGE`N�CYj� AGENCY NAME CONTACT PEAR-SO�Nj PHONE <br /> wW2--REGIONALBOARD <br /> rl-LLA P/YS^ � <br /> a¢ PHONE <br /> f <br /> m (�) NAME ` <br /> W I� ! <br /> QUANTITY LOST(GALL0 <br /> > f!i'GY�p �iQQ�Znlr� <br /> mp UNKNOWN <br /> N <br /> ❑ UNKNOWN <br /> w GATE DISCOVERED HOW DISCOVERED TORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> ❑ <br /> MI U MI d o� r r TANK TEST TANK REMOVAL ❑ OTHER <br /> Q DATE DISCHARGE BEGAN a[�:::]REPLACE <br /> USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> >w Ml d 131 Yl <br /> HAS DISCHARGE BEEN STOPPED 7 y UNKNOWNMOVE CONTENTS ,`LOSE TANK 8 REMOVE E]REPAIR PIPING <br /> PAIR TANK ❑CLOSE TANK d FILL IN PLACE ❑CHANGE PROCEDURE <br /> o ❑ YES ❑ NO IF YES,DATE M M o TANK ❑OTHER <br /> Lip ti SOURCE OF DISCHARGE CAUSE(S) <br /> a< F-1TANKLEAK UNKNOWN ❑ OVERFILL ❑ RQPTURE/FAILURE ❑ SPILL <br /> D ❑ PIPING LEAK ❑ OTHER ❑ CORROSION KNOWN ❑ OTHER <br /> ywa CHECKONEONLY <br /> O ❑ UNDETERMINED OIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w� ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> �y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ <br /> REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> ❑ E%CAVATEd DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(In <br /> az <br /> Fn O ❑ CAP SITE(CD) ❑ EXCAVATE d TREAT(ET) ❑ PUMP d TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ¢� ORW <br /> ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED INA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENTSOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> 5dSGr�f��> Fi�.�s r74NK RE�racy4,[. y�ill'�.TE�7� � lt- i� <br /> fr�n�-SiT� .Q�iff.-r�ifltJ'�,'i<t� P6 ..�°EE4v.2�Y)7v �E7.�iP�'s�•`�!£ 'T�✓E <br /> HWM(A9U) <br />