Laserfiche WebLink
f <br /> ,h _ <br /> UNDERGROUND STORAGE TATIK UNAUTHORIZED RELEASE (LEAK)INTAMWA SITE REPORT <br /> � TLON Sl I, <br /> HAS STATE OFFICE OF EMERG CY SERVK�S ;;AOR L OCALI4GENC^f USE ONLY 4 <br /> 7EMER7GENCY REPORT BEEN FILED 7 ,y{ 1 HERE$Y CERTIFY:fF1AT i ANE A Q>wS1C�1A7ED GDV1 RNlult NT EMPLWY E:AND THAT!HAVE <br /> vEs NO I-v I YES Q q"IS INFORMATION:T4 OFFiCfALS PlIR5U;4NT TQ SECTION 251801 OF <br /> REPORT GATE <br /> CASE s TH TH D 5AFTY <br /> I',: ..;. DATE: <br /> MI ' d o Y Y <br /> M SIG RE,.. f <br /> NAME OF IND)VIQUAL FILING REPORT PHONE <br /> m REGIONAL BOARD COMPANY OR AGENCY NAME <br /> Q REPRESENTING OWNERIOPERATOR fL <br /> LOCAL AGENCY OTHER N L <br /> a <br /> ¢ ADDRESS <br /> • 5� V� �rN' STREET f 512L �"r CfTY !r STATE tP <br /> NAME CONTACT PERSON PHONE <br /> 1 Iy <br /> y a ❑ UNKNOWN l� .�� e� �"`�{ ! 5'I 2/ <br /> a ADDRESS i <br /> cc <br /> (/ljJ S. Lf STREET � �� 1.I CRY` 1 STATE'r✓ ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> NykrcV 07) 3 <br /> a ADDRESS i - 1 <br /> 7Crry N /J' CWM[Y -MR- <br /> CROSS <br /> P <br /> CROSS STREET TYPE OF AREA COMMERCIAL INDUSTRIAL❑RV TYPE Of BUSINES RETAIL FUEL STATION <br /> r' �n� ❑RESIDENTIAL Q OTHER ❑ FARM OTHER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> Lu <br /> J Lu REGIONAL B ARD /PHONEcL <br /> 1 <br /> 1 <br /> (i) 11 NAME OUANTIT'YLOST(GALL 5) <br /> Lu ' U;I! d Le- <br /> A`' n+s UNKNOWN <br /> m 1 <br /> I ❑ UNKNOWN <br /> z DATE DISCOVERED �j HDW DISCOVERED ❑ VENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> M o O.0 Y r ❑ TANK TEST YANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE{CHECK ALL THAT APPLY) <br /> 1 <br /> UNKNOWN REMOVECONTENTS ❑ REPLACE TANK CLOSE TANK <br /> Lu t; M M D U Y Y <br /> HAS DI5jl4ARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> a YES ❑ NO IF YES,DATE 61 5M 1 C).j 2.,o r ❑ OTHER <br /> Lu SOURCE OF DISCHARGE' TANKS ONLYACAPACITY MATERIAL CAUSE(S) <br /> E::] TANK LEAK UNKNOWN S.(1D-n GAL. FIBERGLASS OVERFILL , ❑ UPTUREiFAILURE <br /> PIPING LEAK AGE YRS STEEL CORROSK)NNKNOWN <br /> OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> W Lu CHECKONEONLY <br /> UNDETERMINEI] ❑ SOIL ONLY GROUNDWATER DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> h CHECK Ohl c ONLY <br /> c c ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ ,CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> L)y ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) �n <br /> z ❑ CAP SITE(OD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) Y <br /> CONTAINM ENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(6T) REPLACE SUPPLY(RS) <br /> O TREATMENT AT HOOKUP(HU) NO ACTION REOUIRED(NA) ❑ OTHER(0-1) I <br /> '-rc 01�1_eem ,,7' <br /> co <br /> eA7+,�4 074 <br /> HSC OS IUS7) <br />