Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> .:.:. .. <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES AOR OCALAGENCYsUSE ONLY <br /> Q YES NO <br /> REPORT BEEN FILED? YES NO 1.HE Y CERT{FY THAT E AM A:D $1GNAT>A GLIVFRNME1Fi: IYIP(i3YEE}1NDTHATI HA1fE:: <br /> .R_E_PO__. _T..H...l.S.,.N_ QN. LQCALAXFICALS 0 - .. I-ft-- <br /> l TFPURSUA[T T . GTON <br /> THE# 0. <br /> REPORT DATE CASEX <br /> E <br /> M D D f/V v 51GNED ::: .; . .; TE <br /> A E OF INDIVIDUAL FILING RT PHONE SIG RE> 59th <br /> m <br /> 44m, <br /> C3 REPRESENTING O OWNER/OPERATOR REGIONALBOARD I COMPANY OR AGENCY NAME <br /> p OCALAGENCY [:] OTHER <br /> a <br /> Q A RESS <br /> STREET CRY STATE <br /> NAMECONTACT PERSON PHONE �1 Z <br /> EIUNKNOWN <br /> aco <br /> ADDRESS <br /> cc <br /> 213c� <br /> w r <br /> STREET LJ-1.Wr-1 CfTy nj4qQ1-5 11 <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> to ( ) <br /> Ua ADDRESS <br /> OliSTREET �T CRY P <br /> yCROSS STREET TYPE OF AREA 0 COMMERCIALJ5�JINDUSTRIAL a RURAL TYPE OF BUSINESSETAIL FUEL STATION <br /> IW 6 F7 RESIDENTIAL 0 OTHER 0 FARM OTHERJ�W L <br /> LOCALAGENCY AGEN YNAME tDNTACTPER N PHONE <br /> PzN 1 <br /> w <br /> w ENAL BOARD PHONE <br /> 4 Lei ot� 2 1�) �u <br /> w (1) NAME QUANTITY LOST(GALLONS) <br /> 1;o <br /> �++ �NKNOWN <br /> 0 (2) <br /> N <br /> UNKNOWN <br /> i DATE DISCOVERED e/�1 HOW DISCOVERED IN <br /> a INVENTORY CONTROL 0 SUBSURFACE MONITORG 0 NUISANCE CONDITIONS <br /> Lu <br /> M o (,!v y TANK TEST TANK REMOVAL O OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M o o v y UNKNOWN F-] REMOVECONTENTS 0 REPLACE TANK CLOSE TANK <br /> > HAS DISCHARGE BEEN STOPPED? E-1 REPAIR TANK a REPAIR PFING CHANGE PROCEDURE <br /> -p YES E:] NO IF YES,DATE M M !moo DI y y Q OTHER <br /> SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> 07 <br /> 0 TANK LEAK -15�<UNKNOWN O GAL, Q FIBERGLASS O OVERFILL F7 RUPTURE/FAILURE <br /> O PIPING LEAK AGE YRS STEEL 0 CORROSION 7< UNKNOWN <br /> O OTHER 1�r UNKNOWN 0 OTHER O SPILL O OTHER <br /> w w CHECK ONE ONLY <br /> UNDETERMINED SOIL ONLY a GROUNDWATER 0 DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z� <br /> a .5—<rSITE NVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) 0 CLEANUP IN PROGRESS[::] SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U 0 NO ACTION TAKEN [::] POST CLEANUP MONITORING IN PROGRESS Q NO FUNDS AVAILABLE TO PROCEED 0 EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> F3 zz ❑ CAP SITE(CD) EXCAVATE 6 DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> Lu <br /> � O CONTAINMENT BARRIER(CB) O EXCAVATE 8 TREAT(ET) PUMP d TREAT GROUNDWATER(GT) r REPLACE SUPPLY(RS) <br /> O TREATMENT AT HOOKUP(HU) NO ACTION REQUIRED(NA) a OTHER(OT) <br /> URTt1 r�SZ�LT� �`s�c1�N�-'T I/U t L-� I UIP�t� `tom 1JETE-l-'mlw0 Ve Ni�w(D�7 I'Pb <br /> �XT t9 F L�NTF�N II N►`1�� 1 14tit�l%11 R-�� t3�[' -R P Pf3P el t `I� <br /> ll-4A--L era,-j 6 vc---#J c <br /> HSC 05(1,87) <br />