Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES "FOR I.00AL"AGENCY USE ONLY <br /> ❑ YES NO REPORT BEEN FILED ❑ YES ❑ NO I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED-THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON:THETIN ' UCTION SHEET.O THE BACK PAGE OF THIS FORM <br /> REPORT DATE CASE # <br /> SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE I SIGNATURE <br /> REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONA BOARD COMPANY OR AGENCY NAME <br /> p LOCAL AGENCY ❑ OTHER <br /> ADDRESS // <br /> OREE CITY Lr'�-/'� STATE / pa <br /> NAME / CONTACT PERSON PHONE �y <br /> yG <br /> ¢ • / G vleo 62 LE& UNKNOWN we, z zkvm ky X�e U 7v (!(' 2 X24 <br /> ADDRESS X 11/•� A /ly' {5��/'/q�/�/ /! /V���///(/A}>- S7 <br /> 1 ' D V Oi STHEET �V V J v u , CRY � ' - • V � y AA �v <br /> FACILITY NAME (IF APPLICABLE) OPERATOR PHONE <br /> 0 CP k6 ViZO A) <br /> UADDRESS '%^ /'/% i%� / r'' /��/�/��/�/y /�J j� 2//J /} <br /> 0 ✓ / 4/ A/wREET V - /" J ✓`/ T-�CrtY Cp 9� „� / V <br /> CROSS STREET <br /> T �S L vv <br /> O LOCAL AGENCY AGENCYNAVE CONTACT PERSON PHONE <br /> w ac <br /> ww REGIONAL BOARD <br /> � a <br /> v ,� w G G � (HD`G�3cl7I S6CD <br /> m w (1) � NAME QUANTITY LOST (GALLONS)LONS) <br /> UNKNOWN OWNO Ile � wl ,J <br /> 51 2) <br /> ❑ UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> MI MI DI DI A y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> ❑ UNKNOWN ❑ REMOVE CONTENTS ❑ CLOSE TANK & REMOVE ❑ REPAIRPIPING - <br /> w M M d 0 YJ Yl <br /> p HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE [] CHANGE PROCEDURE <br /> Q <br /> o ❑ YES ❑ NO IFYES. DATEMI MI y Y F-1 REPLACE TANK E:] OTHER <br /> SOURCE OF DISCHARGE SE($) <br /> i< °' ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> a <br /> yO ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w CHECK ONE ONLY <br /> O UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ww ❑ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMNTED ❑ POLLUTION CHARACTERIZATION C <br /> r ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS W <br /> O y ❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVEFREEPRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br /> ,SEES KIMCEj <br /> 00 ❑ CAP SITE (CD) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY IRS) <br /> w a ❑ CONTAINMENT BARRIER (CS) ❑ NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br /> K <br /> ❑ VACUUM EXTRACT (VE) ❑ OTHER (OT) <br /> /Al eil Fro Z4 w c0 ✓u! 0 ti <br /> nVta reed <br /> S de seems iyre � H r� `O„F`CSN 7�f/�tiN ��ru <br /> HSC Mlmo) <br />