Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE T <br /> _. <br /> H TAT OFFICE OF EM RG CY <br /> EMERGENCYENC <br /> HAS E CE E SERVICES <br /> ❑ YES NO REPORT BEEN FILED? YES NO <br /> HR !'tAT3F1!iH1�T.I A?E p $ t GQ+ERNNNf. MF�tt�Y Af3 FT f HAVE:: <br /> D,THIS. 1FaftMAi}Ck�I TO F(Gf, PURSIII%t�] fEf SC�7tON 251807 OF: <br /> REPORTDATE CASEX Tbl <br /> .. <br /> % < . <br /> M M <br /> Dllyloyl <br /> DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> ® r <br /> (2 67 ) <br /> 0 REPRESENTING ❑ ❑ COMPANY OR AGENCY NAME <br /> OWNER/OPERATOR REGIONAL BOARD <br /> ® LOCALAGENCY ❑ OTHER „� <br /> a <br /> ADDRESS <br /> b!/ STREET CITY STATE ZIP <br /> NAME CONTACTPERSON PHONE <br /> za� ❑ UNKNOWN j (2 ) <br /> nQ ADDRESS <br /> STREET cy,4h mp CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o ( ) <br /> u¢ ADDRESS <br /> STREET Ze4 CTTY r COUNTY 3 1 ZIP <br /> CROSS STREET TYPE OF AREA ❑ MERCIAI INDUSTRIAL❑RURAL TYPE OF BUSINE S E:] RETAIL FUEL STATION <br /> 0 RESIDENTIAL ❑OTHER ❑ FARM Un OTHER <br /> �y LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w J01 <br /> Lu REGIONAL BOARD f PHONE <br /> (i) NAME •QUANTITY LOST(GALLO ) <br /> UNKNOWN <br /> ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ VENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 0.1 IC/ml Y Y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> 12 <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M D D Y Y <br /> UNKNOWN ED REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> w <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> o YES ❑ NO IF YES,DATE M o o v v a OTHER <br /> y SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN t750GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> ❑ PIPING LEAK AGE YRS EgSTEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER UNKNOWN a OTHER ❑ SPILL 0 OTHER <br /> W w CHECKONEONLY <br /> ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER E] DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ON'ONLY <br /> 2 a ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESSO SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> V ❑ 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 /> ❑ CAP SITE(CD} ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> w ❑ CONTAINMENT BARRIER(CB) F--] EXCAVATE&TREAT(ET) ❑ PUMPS TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> z 4F <br /> HSC 05(4AM <br />