Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHO IZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERV ES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED?VES NO Q VES NO pl E IS �HOWNAON HHS � THE <br /> BAN ACCORDING I TOTHE <br /> RE <br /> AT DATE (/�/� 2 CASE• y TON /Flyby/(QT}{E BACK PAG OFT/HI//S Fin/q"M <br /> w / / lr .GDATY� <br /> NA NDIVIDUAL Fl L PO2 PHONE SIG q <br /> m D <br /> REPRES TNG O OWNER/OPERATOR Q REGIONALBOARD NV /AGENCYNA <br /> ¢ LOCALAGENCV O OTHER <br /> S <br /> AD fl S ,/ /0 STREET C JT- 6po 2 7 I \,IT,74 / ✓LiV l� <br /> 21P <br /> TACTERSON �PHHHONNEQ y/(`y�,/� <br /> m �//�"� !/• O UNKNOWN �f/V� <br /> y <br /> O� <br /> y� R yz �N- SID D ca�Aa, � <br /> w <br /> G -ST.�TE /+ 2 � <br /> O �C�IL NAMED �IC BL^��fliC/4"�'• , VZj �7i / R V✓� PHONE <br /> H <br /> � srREEr couwry <br /> y CROSS FWET <br /> �5na <br /> p L NCV AGENCY NAME CONTACTPERSON PHONE <br /> Z i <br /> w <br /> w <br /> wM RE NALBO D PHONE <br /> a< � V l,� CAQ- <br /> NAMEQUANTITY LOST(GALLO <br /> w Q <br /> UNKNOWN <br /> m O UNKNOWN \^ <br /> i TE DI VER D HOW DISCOVERED INVENTORY CONTROL 0/SUBSURFACE MONITOR' G NUISANCE CONDITIONS <br /> /�J1 <br /> M 10 y TANK TEST TANK REMOVAL OTHER <br /> am DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHA E(CHECK ALL THAT APPLY) <br /> w o y r UNKNOWN Q REMOVE CONTENTS CLOSE TANK&REMOVE OREPAIR PIPING tO <br /> HAS DIS AGE BEEN STOPPED 7 I (�/�/� O REPAIR TANK O CLOSE TANK&FILL IN PLACE 0 CHANGE PROCEDURE fX�•' <br /> o VES O NO IF VES,DATE M MI oD i v y F]REPLACE TANK O OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> w O TANK LEAK UNKNOWN O OVERFILL RU RE/FAILURE Ej SPILL <br /> 00 F PIPING LEAK O OTHER O CORROSION UNKNOWN O OTHER <br /> ww CHECK ONE ONLY <br /> ci3 FL O UNDETERMINED SOIL ONLY O GROUNDWATER Q DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> zr O NO ACTION TAKEN 0 PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED O POLLUTION CHARACTERIZATION <br /> �y 0 LEAK BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> Q O REMEDIATION PLAN O CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) O EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) O ENHANCED BIODEGRADATION(IT) <br /> 1�e�cn rw crtu� <br /> 1pQ CAP SITE(CD) O EXCAVATE&TREAT(ET) PUMP A TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> < ❑ CONTAINMENT BARRIER(CB) NO ACTION REQUIRED INA) TREATMENT AT HOOKUP(HU) O VENT SOIL(VS) <br /> O VACUUM EXTRACTIVE) O OTHER(OT) <br /> rsc as Ia9% <br />