Laserfiche WebLink
I <br /> r UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)!CONTAMINATION SITE REPORT ; <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVIC3 AOR LQCALAGENCY, �$E ONLY <br /> ❑ $ REPORT BEEN FLED? ❑YES I`'���'J�� :HEREBY CERTIFY THAT I AM A:DESIGNATED GOVERNMENT EMIPUOYEE AND MT.-1 NA* <br /> REPORTED,:CHIS INFORMATION.TO LOCAi.:O ICIALS;PURSUANT TO SECfION,25107 OF <br /> REPORT DATECASE s THE RMTH ANDS*TY CODE <br /> k <br /> NAME OFFIINDIVIDUAL FILING R RT PHONE <br /> o REPRESENTING V�IOWNEPJOPERATOR ❑ REGIONALBOARD I CO YORAG N <br /> p ❑ LACALAGENCY ❑ OTHER �/ <br /> IL <br /> Lu <br /> STREET CITY STATE - ZIP <br /> NA CONTACTPERS PHONE <br /> �/ ❑ UNKNOWN h� G7 i(i'/Il c<"�/7• V��J �!/ UU <br /> w <br /> STREET CRY STATE j3p <br /> FACILITY NAME(IF APPLICA OPERATOR PHONE jj <br /> L?o%) /77-4f//.. <br /> ADDRESS <br /> SCA <br /> STREETC _ Czip <br /> " <br /> CROSSSTREET TYPE OF AREA COMMERCIAL ❑INDUSTRIAL E::]RURAL TYPEOFBUSINES I RETAIL FUEL STATION] <br /> Al ❑RESIDENTIAL OTHER ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACTPERSON PHONE <br /> w W d 14014-/T� L/! . 2u /-P LU�lc <br /> mw REGIONAL BOARD PHONE <br /> y {t) NAME QUANTITY LOST(GALLONS) <br /> UNKNOWNI <br /> (2) <br /> y ❑ UNKNOWN.! <br /> g DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lu <br /> AIA M U - Y Y <br /> ❑ TANK TEST TANK REMOVAL ❑ OTHER a i <br /> GATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> -1 MI DI 01 11 Yl I Rf UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED Z ❑ REPAIR TANK ❑ REPAIR PIPING CHANGE PROCEDURE <br /> I, YES ❑ NO IFYES,OATE M p .r Y ❑ OTHER <br /> SOURCE OF DISCHARGE �ONL��ACS MATERIAL CAUSE(S) I <br /> ❑ TANK:LEAK UNKNOWN e ei y�T GAL. ❑, FIBERGLASS ❑ OVERFILL ❑ RUPTUREiFALURE ' <br /> ❑ PIPING LEAK AGE YRS ,�I STEELcc ❑ CORROSION UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ^❑ OTHER ❑ SPILL ❑ OTHER <br /> W W CHECK ONE ONLY <br /> v tr UNDETERMINED SOILONLY GROUNDWATER <br /> ❑ ❑ ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED)? <br /> CHECK ONE ONLY <br /> Z b! N i <br /> a ❑ SITE-ANVESTIGATION'IN PROGRESS(DEFINING EXTENT OF PROBLEM) E::] CLEANUP IN PROGRESS❑ SIGNED O7(CLNUPCOMPLETED OR UNNECESSARY) <br /> NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS NO FUNDS AVAILABLE TO PROCEEDVALUATING CLEANUP ALTERNATIVES c <br /> CHECK APPROARIATE ACTON(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP•SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) El ENHANCED BIO DEGRADATION jr) <br /> F-1CONTAINMENTBARRIER(CB) ❑ EXCAVATE 6 TREAT(ETI ❑ PUMP 5 TREAT GROUNDWATER(GT).❑ REPLACE SUPPLYFF <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) OTHER <br /> C�(9 i l C��7 cc.�!7 i.2 � �U ��C i, � �lL✓i rL r�/-r7 r� ✓�- ,,� _�y�i"'�,� - <br /> d �Se f.Sm P i S a/T H Gc-6`si .CP: 1' <br />