Laserfiche WebLink
I Z)I/9v - mme ET ft <br />AD q1-1-1 3 <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERV!S <br />❑ YES NO REPORT BEEN FILED ? YES NO <br />FOR LOCALAGENCY USE ONLY <br />(HER> BY CERTIFY THAT 1 Alu4 R DESIGNATE GOVERNMENT EMPIOYf AN0 THNI.A. AVE <br />REPORTED<THIS INFORMATION TO LOCALi OFFICIALS PURS.UAN TQ SECTION 2511:80.7 OF <br />THE HEALTH AND SAMCODE: <br />j f <br />REPORT DATE <br />OM <br />CASE A <br />SIGNED iNITE <br />/ M ` D / Y Y <br />N F INDIVIDUA FILING REPORT <br />%darn �16le <br />PHONE <br />i y68-3y�o�� <br />SIGNPATON <br />> <br />m <br />a <br />REPRES TING ❑ OWNERIOPERATOR ❑ REGIONAIBOARD <br />COMPANY OR AGENCY NAME <br />`� D <br />cc 0 <br />a <br />LO CAL AGENCY OTHER <br />¢ <br />ADQfjE <br />� // �y �>O <br />5 Aq / �J / J F c J �- <br />i TToaREET STATE I <br />w <br />z¢ <br />NAME <br />f% /� �/ //n� <br />`� Q 6 a Q5 A ❑ UNKNOWN <br />CO ACTPERSON <br />�' <br />PHONE <br />M 9 �� /L 36 <br />R <br />U cc aADDRES <br />w <br />� <br />CRY STATE ZIP <br />o <br />FACILI NAME (IF APPLICABLE) <br />n a'� Car �� sti <br />OPERA R <br />elmo (a <br />PHONE <br />04� 9418-1636 <br />U <br />ADDRESS I % t ! /V 1 / / � ✓� g5z,0 <br />/`/ <br />w <br />STREET RY COUNTY P <br />y <br />CROSS%STREET <br />TYPE OF AREA ❑ COMMERCIAL ❑ INDUSTRIAL ❑ RURAL <br />TYPE OF BUSINESS RETAIL FUEL STATION <br />/ 67 K <br />a RESIDENTIAL ❑ OTHER <br />❑ FARM ❑ OTHER <br />P: <br />LOCAL AGENCY AGENCY NAME <br />S <br />CONTACT PERSON <br />PHONE <br />w w <br />REGIONAL BOARD <br />PHONE <br />y <br />(i) NAME QUANTITY LOST (GALL <br />OWN <br />i <br />(2) <br />6"c ��J(� VCr UNKNOWN <br />DATE DIVE®D <br />OVERED❑ CONTROL'MONITORING F7NUISANCE CONDITIONS <br />HOW STANK <br />D v - y <br />E] TEST Ep/TANK REMOOTHERSUBSU <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />Q <br />UNKNOWN <br />M M D D Y Y <br />❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br />Lu <br />p <br />p <br />❑RREEEPAIR TANK /�❑ PAIR PIPING� ❑ CHANGE PROCEDURE <br />E y, �� PI <br />HAS DISC GE BEEN STOPPED? <br />YES ❑ NO IF YES, DATE M M D D v v <br />` y V A.4�J <br />"' `SER <br />Lu <br />SOURCE OF DISCHARGE <br />TANKS ONLY/CAPACITY MATERIAL <br />❑ FIBERGLASS <br />CAUSE(S) <br />OVERFILL ❑ RU URE/FAILURE <br />❑ TANK LEAK UNKNOWN <br />GAL. <br />❑ <br />❑ PIPING LEAK <br />YRS ❑ STEEL <br />❑ CORROSION UNKNOWN I <br />❑Cc <br />OTHER <br />;/UNKNOWN❑ OTHER <br />❑ SPILL ❑ OTHER <br />Lu w <br />aTERMINED <br />CHA�QNLY <br />❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />z a <br />CHECK ONE ONLY <br />❑ SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) F --]CLEANUP IN PROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />U N <br />❑ 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 />F3 O <br />F7CAP SITE (CD) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) F -]ENHANCED BIODEGRADATION (IT) <br />w <br />❑ CONTAINMENT BARRIER (CB) ❑ EXCAVATE 6 TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />❑ TREATMENT AT HOOKUP (HU) ❑ NO ACTION REQUIRED (NA) ❑ OTHER (OT) <br />v <br />Can ! rn L ' -t�16 <br />z <br />11,/ � �t� ssry�jy/ f Gf// /l �2 l'�d -/-e We Y -A k -f- e <br />mD <br />O Q r v!a <br />"x Wj4mil <br />M <br />