Laserfiche WebLink
F- <br /> i <br /> D C <br /> � y <br /> Y � <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)If CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SEAViCES ;FOR E OCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? 1 HEREBY CERTIFY ( HAVE DISTRIBUTED THIS INFQRMATION:A000RDING TO THE <br /> YES YES NO <br /> ❑ ND ❑ ❑ <br /> DI TIONS -&k ON THE WSTRUCT)DN SHEET ON THE BACK PAGEF TH IS FORM <br /> REPORT DATE CASE s <br /> d d Z Y <br /> ->SIGHEfl ��SATE <br /> NAME OF INDIVIDUAL Fi ING REPORTPHONE SIGNATURE <br /> Lu <br /> REPRESENTING ❑ OWNER/OPERATOR REGIONAL BOARD COMPANY OR AGENCY NAME ' <br /> ❑ �� <br /> LOCAL AGENCY ❑ OTHER �1 7�'' J�'y q�� ���"• ` �r'/ <br />'I Q ADDRESSe—� <br /> y y� N- l� <br /> J <br /> STREET _ CITY ._STATE zla <br /> w NAME z ��, 4"la!� F,4� CONTACTPERSON PHONE VYr ElUNKNOWN �Lci✓�Dr"'� �! _GNZZ.. 7V�-61� <br /> Q <br /> N a <br /> ADDRESS <br /> f � lG� <br /> Gdw., -7�ZO <br /> STREET CITY _ .STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o } <br /> A�DJDREssLf /��• -T�/�W 'r �l�t3l�IYUrI'r�I <br /> ZI1 V 7 _ STREET _ CfTY COUNTY Zip <br /> w CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> W �iq e5,p44VJ �1 �v, �N5-'E�� �L �f4X�VF c14- (z'� )�6�-3�3 <br /> w w REGIONAL BOARD PHONE <br /> Rwc��.Pj <br /> m (1) NAME QUANTITY LOST(GALLONS) <br /> LU 0 6r5�G�.cl " <br /> aJ ❑ 'UNKNOWN <br /> f <br /> Q7 z 0 <br /> w ❑ UNKNOWN <br /> z DATE DISCOVERED .J p� HOW DISCOVERED ❑ INVENTORY CONTROL E] SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Zo <br /> w O-I aaI DpI (,Y f y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARG HECK ALL THAT APPLY) <br /> w <br /> M p y UNKNOWN ElREMOVE CONTENTS CLOSE TANK$REMOVE ❑REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED 7 0 REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> L) <br /> O 0 YES E::] NO IF YES,DATE MI j o YI r ❑REPLACE TANK ❑OTHER <br /> SOURCE F DISCHARGE CAUSES) c / s <br /> w <br /> Z) <br /> Z) TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ R REIFAILURE a' ❑ SPILL <br /> c. m o ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN - ❑ OTHER <br /> m a CHECKONEONLY <br /> U ❑ UNDETERMINED SOIL ONLY ,❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) . <br /> CHEC E ONLY <br /> Luz 71 NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION (� <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS y I <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑. CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTiON(S) <br /> J rrx-aKX FmMTAaS; ❑ EXCAVATE&DISPOSE(ED) ❑, REMOVE FREE PRODUCT(FP) ❑ ENHANCED B10 DEGRADATION([T) <br /> a z ❑ CAP SITE(CO) ❑ EXCAVATE 6 TREAT(ET) E] PUMP 6 TREAT GROUNDWATER(GT)❑. REPLACE SUPPLY(RS) ��— <br /> n O L <br /> w <br /> a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) I✓y <br />( ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT)' . <br /> a - <br /> Spl�- r!g fRo,y !J!r"��2Gt.�v�L Nt�tGifi7� Sore' Gv�YT/u*inl�#r�LpAj <br /> t <br /> 0 /4-t Il c] X7C�c.`u F ra rY Tis«��'�r ro r�/: 4/�S i2G4A-r,-eEd '0(-' ?'ifiE� Gvtac�r <br /> �� HSC 45(N9q <br />