Laserfiche WebLink
0 /1A9P-:;v-- tel- /i1�% <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEA4/ CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SER <br />REPORT BEEN FLED? <br />FOR LOCALAGENCY 0% ONLY - <br />INERESY CeRtIFY THAT AM A DESIMTED GOVERNMENT EMPLOYEE ANDTHAT I HAVE <br />YES YES ND L7 Jam/ <br />[] ND ❑ <br />REFORTED IMS 94FORMATION TO:[OCAL WICKS PURSUANT. TO. SECTION 2518V OF <br />THEHEALTHANOSAFTYCODE <br />REPORTDATE CASE# <br />0.1 M ( L D O Y Y <br />6GHF3 DATE <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE <br />'TF+oA�as PAer <br />(gib) T-61-oYoa <br />,z <br />O <br />REPRESENTING ❑ OWNE(OPERATOR ❑ REGIONAL BOARD <br />OR AGENCY NAME <br />¢O <br />LOCALAGENCY OTHER Cy/�SVa.TA N'�bR.�MY-Qy <br />`COMPANY <br />tT'Ipu h[✓ IA7C_ <br />ADDRESS 3017 kl LL),t,9C' %Z -p, So 1'{4' ) Do F -003C lio COCLCADVA CPc q S670 <br />STREET WY STATE IIP <br />ca�Izy <br />NAME <br />OF S-7VCK 0A) L'Z-r:utyr;cnPM�•s� k�ucy <br />CONTACTPERSON PHONE <br />�A p3i-88L1 <br />urs <br />UNKNOWN <br />4e R.AlL WXLYA--P— 1 <br />ai <br />ADDRESS as LN5- locsl;L A•Vi_ ST-ocvqk-b+t) CA 952c,Z <br />STREET C" STATE op <br />FACILITYNAME(IFAPPLICABLE) <br />OPERATOR <br />PHONE <br />Hca-Aev-- <br />I <br />ADDRESS <br />STocFxo+� SAw 3aAq�I,J 952oZ <br />(96(r W�'3s WtSCiLA1,GSTREET Cry NY P <br />yCROSS <br />STREET <br />TYPE OF AREA COMMERCIAL [:D INDUSTRIAL ❑ RURAL <br />TYPE OF BUSINESS ❑ RE AnLLFF��yL'C <br />RESIDENTIAL ❑ OTHER <br />O FARM BOTHER <Vrt 7bi M N+i_ <br />�. <br />m <br />LOCALAGENCY AGENCY NAME <br />`jAA3 ]VAc?v0- C�OJ-AT`{ LNVIKUAl MG-� A- <br />CONTACTPERSON <br />PHONE <br />wW <br />OcNo.-+ <br />["A\NA Ahp�� <br />(aJ�) Y6ff-3yb& <br />w <br />REGIONALBOARO C�.AIT Gp pA- �ZE61DN.4t,, wML'�QV.,... <br />PHONE <br />i� <br />l3o pry® -I .NTw VhL L� L�S,a, <br />n���A lt'Z..�IS <br />(916) Yby_Y7► 9 <br />(1) NAME OUANTfTY LOST (GALLONS) <br />w <br />° <br />VA)Y-AJOWA) FOL'Z. UNKNOWN <br />(2) <br />r� - <br />❑ UNKNOWN <br />i <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />w <br />OM IkM 3D 1 O y <br />❑ TANK TEST TANK REMOVAL ❑ OTHER <br />o Yl v <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />�/ <br />[P UNKNOWN <br />REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br />w <br />M M D o r YJ <br />ANK PIPWO ❑ CHANGE PROCEDURE <br />T24' <br />HAS ESTOPPEDYES, <br />V SRGE❑BENO DATE G I' <br />3 <br />0OTHER -a %J 'U'O Aa IC <br />.1 D I D v 7 Y <br />SOURCE OF DISCHARGE <br />TANKS ONLY)CAPACITY MATERIAL <br />CAUSES) <br />EET"TANKLEAK ❑ UNKNOWN <br />SOJ GAL, ❑ FIBERGLASS <br />❑ OVERFILL ❑ RUPTUREiFAILURE <br />PIPING LEAK <br />AGE YRS �TEEL <br />D CORROSION ❑ UNKNOWN <br />❑ OTHER <br />EZ�UNKNOWN ❑ OTHERS <br />PILL OTHER e0) 3CWIL6- <br />ww <br />CHECK ONE ONLY <br />a <br />UNDETERMINED O SOIL ONLY O GROUNDWATER ❑ DRINKING WATER(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />2 N <br />CHECK ONE ONLY <br />CLEANUP IN PROGRESS a SIGNED OFF COMPLETED OR UNNECESSARY) <br />a <br />❑ SITE INVESTIGATION IN PROGRESS (DEFINING E%TENTOF PROBLEM) (CLEANUP <br />UN <br />❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATINGCLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />5 z <br />CAP SITE (CD) [I�KE%CAVATE 6 DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />50 <br />2'I <br />CONTAINMENT BARRIER (CB) ❑ EXCAVATE B TREAT (ET) ❑ PUMP& TREAT GROUNDWATER (GT) REPLACE SUPPLY IRS) <br />❑ TREATMENT AT HOOKUP (HU) ❑ NO ACTION REQUIRED INA) ❑ OTHER(OT) <br />y <br />z <br />w <br />i <br />HSL m HAIL <br />