Laserfiche WebLink
ff <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE fLEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />REPORT BEEN FILED 2 <br />QB LOCALAGENCX USE QNC Y �* <br />(; (REBX RTIFY THAT I AM A DEMO IATI"D GQVERNMENT EIMPLOYEE AND THAT I HAVE <br />❑ <br />YES NO YES ❑ <br />REPORTED';THIS.INFORMATION.TO LOCM. t,F(C(ALS PURSUANT TO &ECTION 2518th OF <br />THEX. E SAY SDE <br />REPORT DATE <br />CASE # <br />M <br />M d o Y Y <br />SIQNED .... .' :..: _::.. DAT£ <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE <br />/ <br />- 7 <br />REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD <br />COMPANY OR AGENCY NAME <br />LOCALAGENCY E:]OTHER <br />�-v`f <br />w <br />ADDRESS <br />l v a <br />/ <br />STREET <br />CITY STATE ZIP <br />NAME <br />CONTACTPERSON <br />PHONE <br />w <br />y <br />❑ UNKNOWN <br />/ <br />r !r /I a 0 <br />a <br />wwa4l! <br />ADDRESS <br />e®/ o® �t r <br />e' !n C <br />cc <br />9 7 STREET <br />CRY STATE P <br />FACILITY NAME (IF APPLICABLE) / <br />�ilO%'a.,% <br />OPERATOR <br />PHONE <br />rl h/ <br />/i <br />7®/7 <br />(((Oq <br />ADDRESS <br />r <br />r/ OatzLflm, <br />W <br />CRY CoUtdTY <br />TYPE OF BUSINESS STATION.. <br />N <br />CROSS STREET <br />TYPE OF AREA ❑ COMMERCIAL INDUSTRIAL ❑ RURAL <br />ETAIL FUEL <br />r <br />❑ RESIDENTIAL Q OTHER <br />❑ FARM ❑ OTHER <br />LOCAL AGENCY AGENCY NAME & <br />CONTACT PERSON <br />PHONE <br />W2 <br />%�a cwt /GAw l ® <br />V <br />toC <br />� <br />w <br />D- <br />REGIONAL BOARD <br />PHONE <br />(') NAME <br />QUANTITY LOST (GALLON <br />/ <br />UNKNOWN <br />rn <br />(2) <br />alf e s <br />UIdICNOWN <br />z <br />DATE DISCOVERED HOW DI RED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />uj <br />2 <br />In <br />M M o D v Y TANK TEST ❑ TANK REMOVAL ® OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />UNKNOWN <br />❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br />,..w <br />p. <br />M M D 0 Y Y <br />HAS DISCHARGE BEEN STOPPED? <br />❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br />S <br />❑ YES ❑ NO IFYES,DA MM o o Y Y E] OTHER <br />u� <br />SOURCE OF DISCHARGE KS ONLYICAPACITY <br />MATERIAL CAUSE(S) <br />Dg <br />F] TANK LEAK UNKNOWN GAL. <br />❑ FIBERGLASS ❑ OVERFILL ❑ RU EIFAILURE <br />2 <br />❑ PIPING LEAK AGE YRS <br />❑ STEEL ❑ CORROSION UNKNOWN <br />❑ OTHER UNKNOWN <br />❑ OTHER -] SPILL ❑ OTHER <br />w w <br />CHECK ONLY <br />R: <br />UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER <br />❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />F <br />CHECKONEONLY <br />cc <br />❑ SI INVESTIGATION'IN PROGRESS (DEFINING EXTENT OF PROBLEM} ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />tr <br />M <br />NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANIp ALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />o <br />❑ CAP SITE (CD) ❑ EXCAVATE & DISPOSE (ED) <br />❑ REMOVE FREE PRODLcT (FP) F-1ENHANCED 610 DEGRADATION (IT) <br />O <br />w <br />❑ CONTAINMENT BARRIER (CB) ❑ EXCAVATE & TREAT (ET) <br />❑ PU P & TREAT GROUNDWATER (GT) REPLACE SUPPLY (RS) <br />Q <br />❑ TREATMENT AT HOOKUP (HU) ❑ NO ACTION REQUIRED (NA) <br />OTHER (OT) <br />HSC 05(4Bn <br />