Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICE EOR LQCA-AGENCY USE ONLY ; <br /> YES <br /> REPORT BEEN FLED 7 <br /> :tiEfi�81F#kiTIFY.THA I N+E l��ESIGNAT�GOV�RNAF EI�PLpY>E ANq T�L(7 I HA1f ': <br /> ' 'TH)S INFOR11UlT10hYTQ CFFICWS P(3RStJAN T�SECfIOIt 2SSBaT-OF- <br /> REPORTDATE CASE P <br /> VA .. <br /> NAM OF DIVIDUAL FLING RE RT PHONE S TU <br /> REPRESENT OWNE PERATOR ❑ REGIONALBOARD .COMPANYORAGENCYNAME <br /> CL �'OL Cl4L AGENCY OTHER <br /> a ADDRESS <br /> Lu / CITY STATE <br /> UNKNOWN ,CONTACT PERSON PHONE <br /> '.f _ - <br /> a ADDRESS ❑ (Lb[} nk <br /> f()Z- WRt-A) <br /> • 2SP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR Ir STATE PHONE <br /> ADDRESS <br /> l�Z ST Loi 1 <br /> 9sz a <br /> �+ CROSSSTREET trrCoJNTy <br /> LOCALAGENCYAGENCY NAME CONT PERSON PHONE <br /> z LJ rte, //_ <br /> Lu <br /> REGIONAL BOA ` J T& ✓q2b <br /> PHONE <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> ❑ UNKNOWN <br /> ❑ UNKNOWN i <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS 9 <br /> Lu c.��1 <br /> M 4 b /o �r ❑ TANK TEST Ul"TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN <br /> a - METHOD USED TO STOP DISCHARGE(CHECK ALL THATAPPLY) - <br /> W M o 01 YJ VI lr✓ lUKNOWN ROVE CONTENTS REPLACE TANK ❑ CLOSE <br /> TANK <br /> HAS DISCH BEEN STOPPED 9 ! <br /> REPAIR TANK REPAIRPIPWG <br /> CHANGE PROCEDURE <br /> YES ❑ NO IF YES.DATE O ,J ❑ OTHER <br /> n o r r I <br /> SOURCE OF DISCHARGE CAUSE(S) s <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFI L ❑ RUPTURVFAILURE E] SPU 'I <br /> 1 ❑ PIPING LEM ❑ OTHER ❑ CORROSICN E4-WKNOWN ❑ OTHER ` <br /> rtu a CHECK ONE ONLY . <br /> UNDETERMINEDSOIL ONLY ❑ GROUNDWATER DRINKING WATER-.(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY n <br /> Q¢ NOACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERQAT)ON l <br /> cc <br /> �� Q LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY _ ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 3 DISPOSE(ED) REMOVE FREE PRODUCT <br /> z tRX@mX�tCETAL% ❑ (FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT{ET) 0 PUMP&TREATGROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ CONTAINMENT BARRIER(CS) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> w ef/ 6e <br /> _ u. SK-- �' `� <br /> > 1716C 011(7, 1 <br />