Laserfiche WebLink
JJ .lecr�rowlG , � �(r3�3f�� 0a6ty7v ': <br /> I UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT Y <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY ' <br /> ❑ VES NO REPORT BEEN FILED 7 - E d ` <br /> YES � NO 1HEREBYCEFMFYTHATIHAVEDISTRIBUTEDTHISINFORMATIONACCORDINGTOTHE <br /> R,!EEXP�ORT DATE CASE• D45TRIBU710N SHOWN ON THE WSTRUCTX)NSHEETONTH <br /> M 3-1 dq r SIGNED GATE I� <br /> NAME OF INDIVIDUAL FILING REPORT _ PHONE SIGNATURE n nn -- <br /> ( ) _ y FiI liR 1 1 <br /> w REPRESENTING OWN R/OPERATOR REGIONAL BOARD COMPANY OR AGENCY NAME <br />�, g ❑ LOCALAGENCY Q OTHER _ E VIR <br /> ADDRESS MIT/SERVICES <br /> I <br /> MA <br /> I SfREEfAll Cm STATE <br /> NAME _ Ip <br /> /\Ni 7p CONTACT PERSON PHONE <br /> i Q (� V UNKNOWN owl �t(s- ?,we <br /> tiy ADDRESS <br /> wREEF em STATE • /� <br /> a /u. <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE i iP <br /> ADDRESS - •., <br /> W Cm <br /> m CROSS STREET <br /> e v . <br /> i LDCALAGENCY I AGENCY NAME 00 TACTPERSON - I: PHONE:_ <br /> r w <br /> wFN7a i ovn v 1 Lo r. (Zq) 46 Ltlq <br /> aQ REGIONAL BOARld - PHONE . <br /> CLU- Cori o ( I& )'255-351q <br /> w (1) �a NAME QUANTITY LOST(GALLONS) <br /> �oAu - e LJ�k\-I beY\zeYle ' IQNe5 I UNKNOWN <br /> .5 (2) <br /> so p <br /> y0 ' Q 1•l\e.r Y IPL' ATOE <br /> V E TP�I{'I 1 — .i UNKNOWN <br /> DATE DISCOVE/7RED HOW DIS VERED INVENTORY CONTROL SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> DMI M ` 0 0 10,13 3 r TANK TEST TANK REMOVAL OTHER - '1 <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> CINKNOWN REMOVE CONTENTS O CLOSE TANK 8 REMOVE 0 REPAIR PIPING <br /> MI MI c,l Ell Y <br /> l Ylj <br /> p HAS DISCHARGE BEEN STOPPED? I' :F � i O REPAIR TANK O CLOSE TANK d FILL IN PLACE ❑CHANGE PROCEDURE <br /> o O YES a NO IFYES,DATE M r Y QREPLACE TANK QOTHER <br /> SOURCE OF DISCHARGE '. - CAUSE(S) I. <br /> TANKLEAK UNKNOWN d; 0 OVERFILL RUPTURE/FAILURE Q SPILL <br /> mQ _0 PIPING LEAK OTHER { 'E CORROSIONS UNKNOWN O OTHEfl <br /> w w CHECK ONE ONLY III <br /> m a <br /> Q ❑ UNDETERMINED Q LSOIL ONLY GROUNDWATER ED DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY '} "` <br /> if <br /> ? -�❑-�1 NO ACTK)N TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED 10 O POLLUTION CHARACTERIZATION <br /> r LEAK BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> Q w REMEDIATION PLAN O CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY �I! <br /> CHECK APPROPRIATE ACTION($) it O EXCAVATE 8 DISPOSE(EO) O REMOVE FREE PRODUCT(FP) E::] ENHANCED BIO DEGRADATION(IT) <br /> IaEE..crt RnoEvael ;r. <br /> a •� CAP SITE(CD) 'J Q EXCAVATE d TREAT(ET) PUMP&TREAT GROUNDWATER(GT)0 REPLACE SUPPLY(RS) <br /> WO <br /> w a i❑ CONTAINMENT BARRIER(CB) NO ACTION REOUIR D(NA) I] TREATMENT AT HCPKUP(HU) VENT SOIL;1 S) <br /> -� VACUUM EXTRACT NEI <br /> OTHER(OT) <br /> r _ <br /> w /L ' E4\ 1 e vlz T e <br /> IN <br /> M0.7c eeW LtN f. = 23 I/�- ; wax o l u ev\e = 3•� , y �L <br /> wa C Tota\ �CylChes= "2� /L; /Vb��/ / R� _ �i•� �L . / >< l�( PL' _� g�L <br /> 2900 <br />