|
S •..}T��y r`` ._.�r...+.,.� TAT�-_1-� _ _ _ � R
<br /> .'l I ; [y v..��y. -�� r✓ sw r�,�,'+t "rr� used r �A r __ /: �/•• e �y-� r +.f..13 -� 1 b - :l/:!`.-� -- .}
<br /> - 1� °r "+zj• rr ilFNsw :'."!' n � �''•'.. '"�Ste•
<br /> r UNDERGROUND STORAGE:TANK,UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION 517E REPpRT
<br /> _ . _ .
<br /> I 1 EMERGENCY r L.'Js f. :FIRS STATE OFFICE OF EMERGENCY SERVICES
<br /> - '9 ;`'-,REPORT BEEN FLED/- AOR LOCAL AGENCY USE ONLY
<br /> r YES NO. r v – ❑ YESY O. No NEfBY CERTIEYTFUIT=)p1v4 A 6ES7�G�VFItdI.S�Nf EMPLOI �ANO THA [FZ41E -. !
<br /> REPORT DATE . ...,+.� xn CASES H H 82?:9F.
<br /> 4 €HIS QflAdATi01V TO LOCAL CFFICLILS PUFSUANT TO SECTION<.
<br /> y. M r f
<br /> NAME OF INDIVIDUAL FLING REPORT;' _ '
<br /> SIGHEI! LATE
<br /> PHONE 51 RE
<br /> I 4r v "fCSOAM
<br /> i;. o• REPRESENTING Y'1 OW NEAJOPERATOR�,� AEGIONAANY OR NC()IAM
<br /> O �,LOC.ALAG66:,L.16THEA NX
<br /> r ¢ ADDRESS
<br /> <., ♦ i :.az .r, .t_r [r o, f
<br /> �_ •r __.'L•+ } f �F ..mJ�,j h T/r�PJ'��/].w.L Jam. �.J 5- X _` 'r'f" I:T �- Y w '• �
<br /> .4C�at°�^_Fi�r y- -f •/ ' r J 7 • 'r A�fy � � - �� r_ i ,.n {A}•/j ~ '•
<br /> CR.Y
<br /> M �i r ,,
<br /> - , '`�:''itaeR•,t°`i .:"}w'r n c:. Y .. COIF TPERSONrrr� -
<br /> '"7rt u 4 G h 1L. KNOWN. S Z F t r fit,
<br /> [f r. ❑ lTl
<br /> 'a Q AODRESSi
<br /> Ll
<br /> �. r
<br /> N' 't.r1 7" -+-
<br /> ��
<br /> FACLRYNAME(IF PLICAE s y ,n: s„ 1r•..•' OPERATOR {a i
<br /> ar_ _ •r PHONE,., rI
<br /> I, t AD RESSAM
<br /> CMA o
<br /> ! V !V •COUNTY' ��
<br /> CROSS STREET :: f:. - '.r..._ .; ��..= .TYPE OF AREA TYPE 6F 6USINES5'. a
<br /> r Q CQMMERCL4L WDl15TRiAL Q AURAL
<br /> RESIDENTIAL :,'. c AIL FUEL STATION
<br /> Q OTHER Q FRAM OTHJ R 7i� ir%NC! .
<br /> y.. LOCAL AGENCY st r` t• AGENCY NAME CONTACTPERSON PHONE
<br /> w AEGiONAL BOA `PHONE
<br /> A��&I t NAME QUANTITY LOSTAGALLONS)
<br /> �t NKNOWN
<br /> � f rif y
<br /> , _.. -. _ .. .. .. -•-- - - ... ...1, -..lei. .i. *.+-, - '. - `
<br /> UNKNO
<br /> - WFI
<br /> • +- DATE DISCOVERED.
<br /> _.
<br /> 0
<br /> va Eo
<br /> How I
<br /> _ DISCOVERED
<br /> z _ ,
<br /> _ WYENTORY CONTROL 0 SUBSURFACE MONETORNa .',_a. NUISANCE CONDITIONS .-.
<br /> TANK TEST C7 .TANK REMOVAL Q OTHER
<br /> DATE DLSCHARGE BEGAN _"� METHOD USED TO STOP OISGNAFiGE(CHECK ALL THA T APPLY)
<br /> -©' UNKNOWN REMOVE CONTENTS_ REPLAC@ 7ANIC. '-, CLOSE TNVK
<br /> '
<br /> y ']{ - �t�•.:t -fir.: -si. I
<br /> HAS DLSC7•IARGE SEEN STOPPED 7 M . r o _gEPpiR TgJV1( -a CHANGE PROCEDURE
<br /> ti Y' �',.._ -r❑ -AEPAIRPP.WG I
<br /> �_. ..0 -YES.Q,ND ;IF YES DATE
<br /> w SOURCE OF DISCHARGE TANKS ON Y
<br /> w _ h .e _L CAPACITY _4,-ter- �, MATERIAL i CAtiSE(S}
<br /> S,•_
<br /> UNKNOWN H., S` f1_ i +C3AL. .F{BERGLASS
<br /> ?_ - -1 e•a Y r i� t L��'7 OYERFLL AUPIUAE�FALURE '
<br /> ; U •.�frr-+� -�.rr r:tr. r.� H i.-A•-•� t• s-.� w_ .rw�Mii�".y 1._ i.-.-!r -+- z }•.
<br /> a ❑,PIPINGLFJUG! ►r.� � yAGE 3 F -• +YRS 41} STEEL xrl-� x�.'`c,.. -. [❑;CORROSION �-UNKNONM:f kh-• •f
<br /> H 1 I. •'-+ i ' �, .�. r y3r 1• yr 1._s "� Y N��w le Sr f' :.w .'tiz'.n'r� Y, moi. s a.r;:: 'll-.,'s 'l-
<br /> �, 0 QTHER OTHER '� ' ' SPIfL OTH R.
<br /> w '.,CHECKONEONLY`.j'e,:'Li.iF.r..z. :.Si - �, _
<br /> 'C: JG _ J u _ �. . i r �J s `. 1r Tle n:i t•cb..4':�.ar' .,.i' i :q•;
<br /> •-4:! n_ -'A>-'.- ...r•S'- .. +- J ', t!"9-YJ•I+T�t.i.:A' �,i••''};�; si' is:'::':. .i.:
<br /> UNDETERMIN®�'-. 'iSOILONLY -=' _ ��
<br /> ICJ' �', GROUNDWATER ORINKAIG WATER HECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED)
<br /> CHECK ONEONL_Y�y"y'!y}��Mav rr' t� fir •.> 5� •i�.r a� Z. �'.�'A� t � x_ wcna�� !."Xi �- y«�+.:=-. . .v S 1.:,
<br /> ��,lk���T-ra-t't�'- '.!5�.�'-'�•-j..��.rr:�z;,;i' '�"�Br�i�Y'�'H�•��.a��`.'+�i'��,F•".dr. :t�riu�,�;�.;i'rtYS� ,J'.
<br /> Q`srm NVESFIC,AT)ON iN PRwFIES$ EFINN(i EXTENT OF PROBLE CLEANUP IN PAOrGRE33 'SKiNED DFF P.COMPLETED OR UNNECESS
<br /> r- .Z':. --f,- .F.�.�..... . la.
<br /> '' '>•r�; .ti «4: }..,y_��, -roar '.®.. -'«J1: ✓-Zi:^.....C,,,ci`'^•�+iz�'• .:. .:i-:'rr r, S',
<br /> NOACT-IONriIJ�P + '+ROSTC7FAN(FPAAONfTOHrxiwpRoaREssFl1fD9AVAi.ABLETOPROCEED;I -F�IIALLrAT1rlGLiuJcaEIpJIL7EwHATiYEs� �"'.:
<br /> t" •CHECK P�ROPRIATE ACTION(S)(Sr.E BACK FOR CETAILS};•.t, r Y Y - r ic ,� ±ti+ T + Nz
<br /> e S ,.i:• a. PALA r^•'�it AC F TAJL
<br /> i o- d sr' SfTE $rp,�Y�'rE]CCAVA]�E S DfSPOSE(ED) `x Q REMOVE FREE PRODUCT(FPj�'+ ENFIFUJCED BKa DEGRADATION(fT}> r
<br /> k Q �COh[TAWAIENT BARRIER(Ce) Q'EXCAVATE'A TREAT(EC)� + :PUMP 8 TREAT GAOLIIbWATEA(07) REPLACE SUPPLY(RS)�
<br /> t o TREATMENTATHOOKUP(liln NOACTKNlREC#11RED(NA) EA(OT)' •4i •n _`1!�ix�=_•+ti►+s�= r>-+4a�.kyne,-.�a w +n.�.
<br /> - - nsc ns 1471
<br /> f1 ;�
<br />
|