Laserfiche WebLink
C 0 • uu 0 p <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINA ON S REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES Fflp EQCAC'AGENCY:USE:ONLY <br /> REPORT BEEN FILED 7 <br /> ❑ YES NO YESy ❑ NO ]HEREBYCEFT(FYTWA HAVEDIS7RIBUFEQTHI53NFORMATIOIQACCORfllNGTOTHE <br /> REPORT DATE AISTRI8U1I.ON SHOWN ON THE.JNSTRUCTION SHEET ON THE BACK:PAGE OF;THIS FOR�::Mou:2M <br /> CASE S <br /> M MI r .SIGNED, DATE '.! <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATUR <br /> Q REPRESENTING O 6WNERrOPERATOR ❑ REGK)NAL BOARD COMPANY(�OR AGENCY NAMECc . <br /> LOCAL AGENCY ❑ OTHER <br /> w <br /> cc ADDRESS <br /> 30 mac- Z�S crry sft <br /> REST <br /> z,p <br /> J NAME CONTACT PERSON PHONE <br /> o� r 1 I 1►T'fi" f' f1 Z a UNKNOWN V- f ` (/i� V ` 1 �,I <br /> a a ADDRESS <br /> Lu <br /> ST, Zsp <br /> FACILITY NAME(IF APPLICABLE) OPERATOR /PHONE 55 <br /> O 1 1 <br /> ADDRESS 03 ) <br /> Lu erry <br /> CROSS STREET COVNTI <br /> Lu LA 's-1 <br /> O LOCAL AGtICY AGENCY NAME. CCaNTACT <br /> /PERSON <br /> zPHONE <br /> y +1 (�`J 11 <br /> w r c -03� <br /> w w REGIONAL BOARD PHONE <br /> w (1) r ii A 1]j}J y3� T1�,! NAME QUANTITY LOST(GALLONS) O <br /> Lu (114%0�1+'V V 4- ,Di�"CL ilE UNKNOWN O <br /> a3 <br /> co z (2) <br /> U, <br /> ` ❑ UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED - ❑ INVENTORY CONTROL SUBSURFACE MONITORING EjNUISANCE CONOTTIONS <br /> w <br /> w µI MI o aI rr ❑ TANK TEST ❑ TANK REMOVAL OTHER JC <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Dn r r UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK a REMOVE E]REPAIR PIPING <br /> w <br /> rASBEEN STOPPED 7 / � / ❑REPAIR TANK CLOSE TANK S FILL IN PLACE CHANGE PROCEDURE <br /> YES ❑ NO IF YES,DATE M f b r l�'r ❑REPLACE TANK 'tQ`OTHER <br /> URCE OF DISCHARGE CAUSE(S) <br /> j ❑ TANK LEAK E] UNKNOWN ❑ OVERFILL E] RUPTUREIFAILURE SPILL <br /> Z)., <br /> y ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN OTHER <br /> w w CHECK ONE ONLY <br /> rn a <br /> O UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> 3 <br /> w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> j y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O CASE CLOSED EANUP COMPLETED OR UNNECESSAR <br /> ❑ REMEDIATION PLAN ❑ ICL Y) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTIONS) <br /> IS"a"FOR C TA.s7 ❑ EXCAVATE 8 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ENHANCED BIO pEGRADATION(IT) I <br /> w;p ❑ CAP SITE(CD) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP 5 TREAT GROUNDWATER(GT)E::] REPLACE SUPPLY(RS) <br /> L.a TREAZNT AT HOOKUP(HU)❑ CONTAINMENT BARRIER(CB} ❑ NO ACTION REQUIRED(NA) El ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) / OTHER(OT - — 1-1 <br /> co <br /> 0 <br /> J <br /> U <br /> I <br />