Laserfiche WebLink
UNDERGROUND STORAGE TANK UNA Rl E( AK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL`AGENCY USE ONLY „. <br /> REPORT BEEN FILED Y Z HEREBY CEHTIFYTHAT#RAVE DfSfRIBUTEQ THIS)NFORMATION:ACCORDING TO <br /> 0 YES NO YES ❑ NO <br /> 0 _ SHOWN L*fSTRUcTbA SHEkT O_N"n BJ1�K PAGE OF'THIS FORM <br /> REPORT DATE CASE M <br /> �I D 3ISA <br /> TE, : <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SiGNA <br /> � E S Sglot�o�) �6���5�5 co s <br /> w RE EN71NG ❑ OWNERAJPERATOR ❑ REGK)NAL80ARD ANY OR AGENCY NAME <br /> cr LOCAL AGENCY ❑ OTHER Z <br /> ADDRESS <br /> �^• y y �-+r `�J STNEET ��D f%STATE <br /> LU <br /> NAME CONTACT PER ON PHONE y �lzh ❑ NKrLld1 <br /> ¢ <br /> Uj <br /> 4 Acc f OS &j ��4 �5Q-� S� <br /> STREET CITY STATE <br /> FACILITY WE(1F APPLICABLE) OPERATOR PHONE <br /> Z & # X18 r <br /> P ` <br /> a <br /> nDDRE13� ] . J t �3��C 60 J6 !/j p <br /> 0 �.i� (V <br /> N CROSS ST <br /> T C� <br /> AL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> 0' 3' S��Y ,� . t: 3Los Sys <br /> rW <br /> w- <br /> �u uzi REG NAL BO PHONE <br /> y (1) /' / NAME QUANTITY LOST(GALLONS) <br /> �J�1SD/lyJ�, <br /> a J UNKNOWN <br /> r <br /> m Z <br /> to ❑ <br /> UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> wD� g y a g p Y ❑ TANK TEST ❑ TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY} <br /> Q n Y UNKNOWN 0 REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> 0 HAS DISCHARGE BEEN STOPPED 7 0 REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> En g ❑ YES NO IF YES,DATE M u Y ❑REPLACE TANK ❑ OTHER <br /> 0 cu SOURCE OF DISCHARGECAUSES) <br /> ja ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURGTAILURE ❑ SPILL <br /> f v ❑ PIPING LEAK 0 OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> y Q CHECK ONE ONLY <br /> ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER 0 DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z ❑ NO ACTION TAKEN 1:3PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERI7-ATION <br /> LU <br /> cc <br /> y ❑ LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTtON(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BID DEGRADATION(IT) <br /> {AM MGR F WTA&M <br /> Z ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(5T) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> Z �vI S>? S�Snics�7� �v�ll ��crss� G7' riy/fi�n� /. v <br /> P114 > Q r <br /> Ksc 05 WWI <br />