Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY it HAS STATE OFFICE OF ZMERG941CY SERVICES FOR LOCALAGENCY:USE ONLY <br /> REPORT BEEN FRED Z #HEREBY CERTIFY-THAT 1 AM A'r(7ESK��1AT.Eb GOVEFNMF FT ENSPLOYEE I ND THAT.E HAVE:. <br /> ❑ YES NO YES ❑ NO REPORTEE3.THIS,INFORMATION,TO tOCAE CfF(Cu1L5 PURSUANT TO SECTION 25L80T OF- <br /> REPORT DATE CASE 1EiE COflE <br /> Y D Y <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> } <br /> m MPANY OR AGENCY N E <br /> w REPRES CO <br /> M lNG ❑ OWNEPJOPERATOR ❑ REGIONAL BOARD <br /> F- <br /> CC AGENCY ❑ OTHER (� �OGt !� rP ! 7�J <br /> LOC <br /> . —Div. <br /> cut) AODRESS <br /> P. o . C3 �x aoo SaG�C - C q5-13 of <br /> NAMMEEi fir" // /� CONTACT PERSON PHONE <br /> m 99 i~ C "L' I 7 L wI li�c� ❑ UNKNOWN <br /> 4 RDx ao y sr S C� -5a o <br /> 0. <br /> m o . <br /> I STREET CRY STATE IIP <br /> -7 <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> lYlf C <br /> ADDRESS! _ n <br /> W STREET ClfY CWNTY mp <br /> CROSS STREET TYPE OF AREA ❑COMMERCIAL INDUSTRIAL❑RURAL TYPE OF BUSINESS ❑ RETAt L STAT30N <br /> ! ! ❑RESIDENTIAL ❑OTHER ❑ FARM BUSINESS <br /> YYIGGN-Pl4 <br /> LOCAL AGENC AGENCY NAME CONTACT PERSON PHONE <br /> Lpu �a�v►` o a r�1 fS - r-F. rI. ! �-c c l�t�i I�- -� 067)ltbe-3Yao <br /> w REGIONAL BOARD 0 PHONE <br /> eL <br /> cRui <br /> (iy <br /> y NAME OUANTITYLOST(GALLONS) <br /> J <br /> 'IAC I rV f l�vs/Y r� C NKNOWN <br /> (4 <br /> ❑ UNKNOWN <br /> i DATE DISCOVERED �f /� HOW DISCOVERED ❑ INVENTORY CONTROL ❑ USSURFACE MONITORING ❑ NUISANCE OONDI S <br /> o uLij <br /> `I M L (p �v v v ❑ TANK TEST ❑ TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD US TO STOP DISCHARGE(CHECK ALL THAT Y61-<rL UNKNOWN REMOVE CONTENTS ❑ AEPLACETANK TANK <br /> w u M o D Y r <br /> HA7�YES <br /> ARGE BEEN STOPPED 4 ❑ REPAIRTANK ElREPAIR PIPINGCHANGE PROCEDURE <br /> ❑ NO IFYES.OATE /.I /., 3p Oo V YY ❑ OTHER <br /> y SOUACE'OF DISCHARGE TANKS ONLYrCAPACITY MATERIAL CAUSE(S) <br /> �ANK LEAK ❑ UNKNOWN 11 n GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RVPTURE*AILURE <br /> PIPING LEAK AGE _YRS I- 'I STEEL ❑ CORROSION ❑ UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> Lu Lu GHECK ON ONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Lu a S��O <br /> ENVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U CTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> 0 zz ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT)uj <br /> \\\ <br /> CONTAINMENT BARRIER(CO) ❑ EXCAVATE S TREAT(E-7) ❑ P&TREAT GROUNDWATER{GT) ❑ REPLACE SUPPLY <br /> F--] (RS) <br /> ❑ �iTREATMENTAT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) OTHER(OT) <br /> z is <br /> 2 A�s-a d- � .k.1�wu 4, <br />