Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERV FOR LOCAL AGENCY USE ONLY I. <br /> REPORT BEEN FILED? 1 HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> ❑YES �No [:]YES NO REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 251007 OF <br /> REPORTOATE CASES <br /> M MA DATE <br /> NAM OF OIVIDUAL FILING REPORT PHONE SIG TU <br /> r (:Fol) ,Y- — f , <br /> REPRESENTI OWNE PERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> aACKAGENCY ❑ OTHER <br /> ADDRESS //� /} _ <br /> S' /`� :.//✓""yam l� / �T. .> �, `MATE <br /> -/ <br /> w CONTACTPERSON PHONE <br /> ESDn� ❑ UNKNOWN <br /> a ADDRESS <br /> ��� �%; Wf}LA.I uT S'I L©/�I tel✓Z(71 <br /> STREET CRY STATE P <br /> FACILITY NAME IF APPLICABLE) OPERATOR PHONE <br /> AOD 1 nZ E. Wlgt A)Ur- �T LODSTR9SZCITY CMJNTY v T <br /> CROSSSTREET <br /> MFtI tie sree� r <br /> LOCAL AGENCY AGENCY NAME CONT PERSON PHONE <br /> �(Hf REGIONAL BOAROF PHONE <br /> q (I) NAME QUANTITY LOST(GALLONS) <br /> ❑ UNKNOWN <br /> 54 C"ISVL4 A e. <br /> ❑ UNKNOWN <br /> tr DATE DISCOVERED HOWDISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACEMONITORNG ❑ NUISANCE CONDITIONS <br /> 9 �, ��' ❑ TANK TEST ®TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> ml ml III al Yl Yl ER-"UNKNOWN US <br /> WN L� "E^`OVE CONTENTS E::] REPLACE TANK ❑ CLOSE TANK <br /> $� HAS DISC BEEN STOPPED T ❑ REPAIR TANK ❑ REPAIR PIPNG E:] CHANGE PROCEDURE <br /> rXQ YES ❑ NO FYES,DATE ODDI �ly r ❑ OTHER <br /> w SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANK LEAK EYJ UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> ❑ PIPINGLEAK ❑ OTHER ❑ CORROSION 5i--NNIKNOWN ❑ OTHER <br /> ww CHECK ONE ONLY <br /> �� ❑ UNDETERMINED SOILONLY ❑ GROUNDWATER ❑ DRINKNGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w� ❑ NO ACTION TARN F-1PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> tiH <br /> PRELIMINARY AHV SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING <br /> ❑ LEAK BEING CONFIRMED ❑ rt <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUPUNDERWAY }� <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> �eroragoErwq (' <br /> w 8 ❑ CAP SITE(CD) ❑ EXCAVATE B TREAT(ET) Q T4)MP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS S <br /> �Y ❑ CONTAINMENT BARRIER IDS) ❑ NO ACTION REOUIREDINA) ❑ TREATMENT ATHOOKUP(HU) ❑ VENTSOIL(VS) <br /> ❑ VAC(IUMEXTRACT(VE) ❑ OTHER(OT) <br /> w ��ic,-tfu•.- si-� c1Sscss�n�� lvi// /tee ���u,,-ted � c�!cfernunl, <br /> 1lDmtiW <br />