Laserfiche WebLink
UNDERGROUND STORAGE TP NK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE Of EMERGENCY SERVIFOR LOCALAGENCY USEONLY <br /> amu( REPORT BEEN FILED I HEREBY CERTIFY THAT.I AM A OESIC3lATED GOVERNMENT EMPLOYEE AND THAT l HAVE <br /> ❑vEs NO REpppTED THIS INFORMATION TO LOC OFFIC(N.S FNRSUAINT TO SECTION 25)88c.�7 OF <br /> ❑ <br /> YES NO THE HEALTH AND SOFTY CODE.F �� '2r � D <br /> REPORT DATE CASEi /v L ,I, }t /t 3 �'z+ �1 I <br /> 4 MTE <br /> �I { Y SIGNED M ! �D t�v q PHONE SIGNATURE <br /> NAME OF INDIVIDUAL FILING REPORT / _ <br /> a i U+( fel S,it ✓e-4 (' � <br /> m REPRESENTING ❑ OWNEWOPERAT R ❑ REG LBOARD COMPANY OR AGENCY NAME �1 <br /> ¢O LOCALAGENCY E] OTHER <br /> c ADDRESS ��in/ !' �jL,�'Zd/✓ <br /> P! V//77 f B(o s REETv CON/TIACTPERSOON VAPHONE z(w'/ <br /> NAME EJ <br /> � UNKNOWNV <br /> ` <br /> ATER/" DP <br /> a <br /> ADDRESS `J/ <br /> Dm WG�/ <br /> � OPERATOR PHONE <br /> FACLITY NAME(IF APPLICABLE) ( I <br /> ADDRESS . <br /> u cm WY <br /> o srnE TYPE OF AREA COMMERCIAL❑ INDUSTRIAL❑RURAL TYPE OF BUSINESS [:3 RETAIL FUEL STATION <br /> y CROSS STREET ❑ FARM OTHER <br /> ❑RESIDEN IAL ❑OTHER <br /> G'U CONTACT PERSON PHONE <br /> LOCALAGENCY NCY NAME <br /> w L �/V Q1141 PHONE <br /> �w REGIONAL BOARD <br /> VR/� QUANTITY LOST(GALLONS) <br /> NAME <br /> (�) ❑ UNKNOWN <br /> N <br /> e.vi,e- <br /> (ZI N� 1 ❑ UNKNOWN <br /> i DATEDISCOVERED /l IW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORNG NUISANCE CONDITIONS <br /> ❑ <br /> w I `7 ❑ TANKTEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN v 1 v METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> 2 OMUNIC40WN ❑ REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> w M M D D v v TseREPAIRTANK ❑ REPAIRPPNG ❑ CHANGE PROCEDURE <br /> HAS DISCHARGE BEEN STOPPED 7 <br /> ❑ OTHER <br /> 5 �g E:] NO IF VES.DATE n M D� D v <br /> TPNKS ONLY�CAPACITV MATERIAL CAUSEIS) <br /> ? SOURCE OF DISCHARGE <br /> �y 7^� � UNKNO❑ FIBERGLASS ❑ OVERFILL E:] EFALURE <br /> 6 F7 TANKLEAK I �.f UNKNOWN <br /> YYj "YY« AGE YRS STEEL ❑ CORROSION � <br /> PIPINGLEAK UNKNOWN <br /> ❑ ❑ UNKNOWN <br /> OTHER ❑ SPILL ❑ OTHER <br /> ❑ OTHER <br /> ww6 CHECK ONE ONLY <br /> Z UNDETERMINED ❑ SOIL LY E] GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY P WATER WELLS HAVEACTUALLV BEEN AFFECTED) <br /> y CHECK ONE ONLY <br /> aF SITE NVES71GATUN IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> �m ❑ NO ACTION TAKEN E] POST EANUP MON RORNGINPROGRESS ❑ NDFUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANWALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BAC FOR DETAILS) <br /> a 4 ❑ CAP SITE(CO) F-1EXCAVATE a DISPOSE(ED) ENHANCED BK)DEGRPDATION(IT) <br /> ❑ REMOVE FREE PRODUCT(FP) ❑ <br /> wr ❑ PUMPA TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ IXCAVATE6 TREAT(ET) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ <br /> NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> nder�I^o .n S7�ra e s7/c r�ai,eve� Pu/LfZ, S. <br /> �— in GW iGL /�� i-e u Tie �v '�yr/v�:UfG/ 'd <br /> 4r4r5eSs o� cor✓<rrM7�ei✓ fJ5 /�1 ir2�d b1v <br /> �,.,.rf z xfeti <br /> M9COSIMn <br />