Laserfiche WebLink
o <br /> UNDERGROUNDT AGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITET <br /> EMERGENCY HAS STATE OFFICE OF EMERG CY SERVICES pq LQCALgGENGY USE ONLY <br /> REPORT BEEN FILED? )HEREB1f f„'EFTY:fHAT)AM',R aE$X EATEfl 430%FER NT. MPLOY� ANO)THAT)NAVE <br /> ❑ YES O YES ❑ NO <br /> ._ :. C0 D TkFORMAT) O € KPURSUANT TO.:SECT(O ::251 OF: <br /> REPORT DATE ;C/g CASE <br /> M A D D V Y ,::SIG D. RATE; . <br /> .. .. ... ... . .. ... <br /> NAME OF INDIVIDUAL FILING ORT PHONE SIGNATU E <br /> > <br /> V07 )% <br /> REPRES TING OWNER/OPERATOR F REGIONAL BOARD COMPANY OR AGENCY NAME <br /> °CLOCAL AGENCY ❑ OTHER AJ <br /> a <br /> cr ADDRESS <br /> qqSTREET CrfY STATE ZIP <br /> AME NTACTPERSON PHONE <br /> y� ❑ UNKNOWN ®2 <br /> a ADDRESS <br /> Q <br /> STREET CITY STATE P <br /> FACILITY NAME(IF APPLICAB E) OPERATOR PHONE <br /> Q ADDRE <br /> STREET CITY CCU P <br /> CROSS STREET TYPE OF AREA COMMERCIAL INDUSTRIAL❑RURAL fYPE OF BUSINES ❑ RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER ❑ FARM OTHE , f <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> 0) ool <br /> w <br /> uiq�?1349/0 <br /> REGIONAL BOARO PHONE <br /> (t) NAME QUANTITY LOST(GALL S) <br /> o <br /> �urilo� UNKNOWN <br /> (2 <br /> ❑ UNKNOWN <br /> I DATE DISCOVERED NOW DISCOVERED ❑ INVENTORY CONTROL Q SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lu M M o o y y ❑ TANK TEST TANK REMOVAL E]mi <br /> DATE DfSCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w <br /> mi M I DI DI Yl y in UNKNOWN REMOVE CONTENTS ❑ REPLACE TANK EeCLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p YES ❑ NO IF YES,DATE a alD D Y Y ❑ OTHER <br /> w SOURCE OF DISCHARGE TANKS ONLYCAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN GAL, ❑ FIBERGLASS ❑ OVERFILLRUPTURE/FAILURE <br /> ❑ PIPING LEAK AGE YRS E:] STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> Lu T CHECK ONE ONLY <br /> ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ON'ONLY <br /> zm ul <br /> 0 SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) 0 CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cr <br /> cc R <br /> U ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> O F-] CAPSITE(CD) F--] EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> 2� ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> s g Via- /�t,� n <br /> l 11� — 1 HSC 05caBn <br />