Laserfiche WebLink
t <br /> UNDERGROUND STORAGE TAUNAUTHORI ZED RELEASE (LEAK)/c TAMI NATION SITE REPORT <br /> EMERGENCY :, - - ,STATE TANK tD x <br /> HAS STATE OFFICE OF EMERGENCY SE VICES <br /> YcS NO REPORT BEEN FILED? YES NO ,` <br /> REPORT DATE (�(/' LOCAL CASE ar - REGIONAL BOARD CASE 0 F US EPA ID R <br /> 6D Q Y <br /> NAME OF INDIVIDUAL FILING REPORT PHONE. StGNAT E <br /> D <br /> w REPRESENTING 0 LOCAL AGENCY ❑ OTHER COMPANY OR AGENCY NAME <br /> rc X OWNER/OPERATOR ❑ REGIONAL BOARD <br /> IL <br /> A Id <br /> OOf S C/v!� \//� "5 1/VAt ll!S/ <br /> rr�(//(f STREET - GITY... STATE Zla v <br /> I >' NAMEECONTACT PERSON PHONE <br /> UNKNOWN - c } <br /> a <br /> IL w ADDRESS �f <br /> wJ <br /> XM /°D '9REE7✓ <br /> - CITY _ GtT ZIP/ <br /> O FACILITY NAME.IIF APpLICAsL:£10N OPERATOR ` PHONE <br /> Z <br /> 37�O ADDRESS �'}�JQ-�LJ .[/ l" � � c/Qi i �//• g! ✓I s RE/EUT 'G 7 �� ClTryNTY ZIP <br /> w CROSS STREET TYPE OF AREA COMME=RCIAL ❑INDUST RIAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> F <br /> NC]RESIDENTIAL ❑RURAL ❑OTH€R U UNKNOWN ❑OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE 7 <br /> OC < <br /> z } <br /> w <br /> z R GIONAL BOARD <br /> Z� <br /> wu <br /> W- Z, <br /> d q TSCD <br /> f , <br /> w CAS Y (ATTACH EXTRA SHEET IF Nff EDEO) NAME QUANTITY LOST (GALLONS) <br /> UD . /^' <br /> <>. f- UNKNOW- <br /> ,J <br /> 00 <br /> m> <br /> (2) 1 t I I I I I UNKNOW <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROLTANKii ❑ SUBSURFACE MONITORING <br /> ROUTINE.MON)TO RING ❑ REMOVAL �..1 NUISANCE CONDITION; OTHER: <br /> Qz <br /> ww DATC DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY} <br /> >f <br /> Ow .REMOVE CONTENTS <br /> Uk D 6 Y YI UNKNOWN <br /> HAS DISCHARGE STOPPE Q? _ REPLACE TANK �T�ICLOSE TANK <br /> I f �r <br /> Om � �RE PARR TANK LJ REPAIR PIPING j-'ICHA NG£ PROCEDURES <br /> a OYES NO IF YES, DAT.E� � M M 7. Y *Y ❑OTHER <br /> OU CE(S) OF OfSCHARGE TANKS ONLY/CAPACITYv' GqL <br /> CAUSE(S) <br /> _ 771g -17- T(I TANK LEAK ❑ UNKNOWN ,�. l_j OVERFILL ❑CORROSION � <br /> AGE vRS. (_j UNKNOWN <br /> U <br /> W PIPING LEAK MATERIAL �1 <br /> U __�RU RUPTURE/E/FAILURE � S.P?LL <br /> T STEEL E-I FIBERGLASS <br /> 0 OTHER ISPECIFYI - ❑OTHER UNKNOWN 71OTHER <br /> RESOURCES AFFECTED WATER SUPPLIES AFFECTED THREAT- N-- e <br /> \O YES NO THREATENED UNKNOWN YES NO ENE-0 KNOWN WELLS <br /> Y AIR (VAPOR) ( 1 PUBLNG <br /> IC DRIKIN - rr ( I <br /> u r SD❑ L� IWATER I`� F- 'D <br /> l I <br /> w SOIL SVADOSE ZONE) a ❑ �� PRIVATE DRINKING r r � 7 <br /> L <br /> GROUNDWATER ❑ ❑ WATER �� `-� I7 {AJ <br /> Y ` <br /> Ind SURFACE WATER OR STORM DRAIN ❑ SLI ❑ ❑ INDUSTRIAL n ❑ �� <br /> W u ti/ <br /> IU, BUILDING OR UTILITY VAULT AGRICULTURAL �� n ❑ <br /> OTHER (SPECIFY) �� ❑ u L_1 OTH ER IS PE C I FY) ❑ 171 ❑ <br /> W <br /> r GROUNDWATER BASIN NAME <br /> UNKNOWN I ( <br /> �rs f: <br /> 2 <br /> COMMENTS: <br /> H <br /> z <br /> w <br /> z <br /> o <br /> U <br /> COMPLETE AND ATTACH A CLEANUP TRACKING REPOR! IF ANY CLEANUP WORK:OR PLANNING HAS STARTED ASC 05 (10/051 � <br />