Laserfiche WebLink
t 7s <br /> 4i0iRGROUND ST4� GE Talmo l0kt I ' iZEp RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFA OF EIlRGENCY SERVk:E3 <br /> ❑YES <br /> REPORTSEEN FLED 9 a YESNb �t Wr1lV <br /> ( 1 [E!!THIS 11F (�INI ACfwORtl�K30 <br /> ' REPORT DATE CASE s. rt NISTAU+(ON Sy>E CbAt 7H� AIrIC PAGE; <br /> fiOF F1LMKiRNORT-- PHONE SIGNATURE <br /> SL IT1Nf3 Q aYINEA7t5PERATOR ❑ REQIONAL', ARd �Z=lklfb <br /> NAME <br /> SAGENCY ❑ OTF" <br /> i <br /> _STgElR 8TA - Y <br /> ADDRESS <br /> i <br /> NAME CONTACT MOON PHONE <br /> a ADDRESS Ch <br /> aTnrcr crrY ZIP <br /> srATe <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> _UA - Lit <br /> N <br /> i <br /> L AGENCY NAME %eNTACTIPERSON PHPNE <br /> 1 lax <br /> c ) <br /> BOARD PHONE <br /> W ( QUANTITY LOST PALLONS) <br /> r + <br /> = DATEMmHDw F-I ,d/V NTORY CONTROL FlSUSSURFACE MONITORm ❑ NUISANCE CONDITIONS <br /> 01 ,44'# ❑ TANK TEST <br /> REM OY71(, O'fogR <br /> DATE.' E BEGAN - METHOD GiETO S DISCHAyR(E(CHEOK ALL THAT APPLY) <br /> (ANm4TS�oLOSE TANK 6 REMOVE E_ REPAIR PIPING <br /> 9EfN ' 9 REPAIR TANK ❑CLOW TANK 8 FILLIN PLACE ❑CHANGE PROCEDURE <br /> I YES;❑ NO F YE&DATE REPLACE TANG ❑OTHER <br /> SOL4MC)F DOOHARBE CA(NSE(S) <br /> ❑ TANK LEAK I <br /> ••��"""""UNKNOWN ❑ OVERFA,L ❑ RUPTURE/FAILURE E-1SPI.L <br /> El PIPING LEAK . OTHER ❑ CORROSION Q UNKNOWN ❑ OTHER <br /> ftCHECK ONE b.PLY <br /> UNDPGRMPM W,SOII.ONW Y - Q GROUNDWATER ❑ DRINKING WATER-(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHEMKONEONLY <br /> NO ACTION TAKEN ❑ PREL"I MRY SITE ASSESSMENT WORIKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ❑ LEAK BEING CONFIRMED ❑ P"INARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> REMEMMON PLAN CAStCLOSED LEANUP COMPLETEDOR UNNECESSARY), CLEANUP UNDERWAY <br /> r <br /> CHECK APPOOMATE ACTION(S) EXCJIVATE A DISPOSE(ED) ❑ REMOVE F#*PRODUCT(FP) Q ENHANCED BK)DEGRADATION(n) <br /> iles+�e•c[anatrxel <br /> ❑ CAP BITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP S TREATGROUNDWATER(GT)Q REPLACE SUPPLY(RS) <br /> CONTAINMENT BARRIER 1CM ❑ NO ACTION REQUIRED(NA) Q TREATMENT AT HOOKUP{HU) ❑ VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) ❑ OTHER(m <br /> zfm <br /> ti <br /> bl- <br /> b� <br /> t © r=ue-I OAJD=lw� . <br /> X050" <br />