Laserfiche WebLink
C � <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR.LOCAVAGENCY:IJSE;ONE Y <br /> REPORT BEEN FILED 7 <br /> ❑ <br /> YES No ❑ YES NO 1FiEREBY:CiRT)F`(THATt)PAVE.nrSTRIBUTEDMIS INFORMATIONACcWO.I.NGTOTHE: <br /> REPORT DATE �f CyySE*. <br /> >2 I UTION OWN ON CT1O SHEET ON TH KP OF FOH <br /> J .> <br /> al b MI d y -SIGNED:: oA <br /> NAME OF INDIVIDUAL FILING REPORT 7J <br /> PHON i sO Sr <br /> m <br /> REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> �) <br /> LOCAL AGENCY [:] OTHER f'f/AV it <br /> A15OFIESS 4h �/'""••"/�)��'���'���✓Q <br /> lei <br /> SF4- II�R/ l [f/V/�..- <br /> w NAME gWX <br /> PHONE I, <br /> . <br /> F3� UNKNOWN DLe�/ 7• <br /> z <br /> ad ADDRESS I <br /> 151� � aT.i FACILITY NAME(IF APPLICA OPERATOR PHONE (� <br /> ADDRESS L�/�/+� <br /> w �' I cm <br /> STREET <br /> y CROSS STREET ' <br /> �osre <br /> c7 LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> JUJ U �/ U �'r' ��1 i/i Ivv V //II /��✓+ j��✓ I <br /> a aIO REGAL BOARD /v'• <br /> PHONE <br /> �t N 6/4)935-3-t L.5 <br /> NAME QUANTITY LOST(GALLONS) <br /> w0 VOO U/ <br /> Z> f UNKNOWN <br /> u1 f2) G/ <br /> D 3 �SCi c.� G:� UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> { <br /> E]9 TANK TEST 1 ❑ NK TAREMOVAL Ll OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> wra d r <br /> UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE C:]REPAIR PIPING <br /> l x <br /> p HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK CLOSE TANK&FILL IN PLACE.E]CHANGE PROCEDURE <br /> oYES [:] NO IF YES,DATE OM 7 6 O �r ❑REPLACE TANK ❑OTHER <br /> RCE OF DISCHARGE CAUSE(S) <br /> w <br /> ❑ARK LEAK uNKNOWN ❑ OVERFILL ❑ RUPTURErFArLURE ❑ SPILL <br /> y ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> Lu w CHECK ONE ONLY <br /> N a <br /> ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITEASSESSMENTWORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> uj <br /> =w ❑ LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS j <br /> V ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY P! <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE d DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 1910 DEGRADATION(IT) <br /> Ike RUX toy WTA�% <br /> aZ <br /> ❑ CAP SITE(CD) EXCAVATE b TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> U <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTK)N REQUIRED(NA) E:] TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT)yd <br /> w �A�'✓• i`''ce l !�/—� _ _ !J <br /> O <br /> . list 05 iw1 <br /> II <br /> .'si <br />