Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> : <br /> HAS STATE OFFICE OF EMERGENCY SERVICES i>#>:;:> <:>`E`»».. .: >'.. ..: ...;: <br /> EMERGENCY ... :.. ... <br /> ❑ YES ❑ NO REPORT BEEN FILED? ❑YES ® NO #J � R1 >f:lllr41: # :. Mlllat:Aid fl1t'd HAVE; <br /> .....i�. £#IS S1FQEi1wiATi( t TE9.f�QCI�l.1 1 PkIRSUAA(T TQ WINNIX-1:10 <br /> (0 <br /> REPORT DATE CASE 11 <br /> ;THS ✓ ....................:>? ;: ?"'.?'>?» "<:::;: ::... <br /> yj <br /> : <br /> M M :. ....... >::;::;::o:`:•;:�:::�;<:•:;;:::c>:r;x::;: o>::.»: o;;r•:;;:o;x::a:.:;:::::r.:::'::'iG::>:::.. <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGNATUff <br /> erAfim6�10-h l,e-_ (q14) $(0I ®40'0 I w <br /> REPRESENTING ❑ OWNER(OPERATOR ❑ REGIONAL BOARD I COMPANY OR AGENCY NAME <br /> s <br /> ❑ LOCAL AGENCY OTHER r SE'Goe- x7v%4 1-n U b't uc l 1 TL c. <br /> � ADDRESS � <br /> -3o rl lie ' ®OLd e =N1+cI� ® (Sr 01�G� �F <br /> STREET'RCRY <br /> STATE zr <br /> NAME CONTACTPERSONPHONE <br /> rl - E 1ev'� Th C, ❑ UNKNOWN b 17c. NInv10 c ) <br /> a ADDRESS / n Tx <br /> R ® tJ V 111 <br /> STREET CRY STATE P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> esGill <br /> ADDRESSy( aQ (�L 61 <br /> 2.S(10 w�+ G a"+,L',KA_ T�rry $ �53�� <br /> CROSS STREET jj'J� .! TYPE OF AREA ®COMMERCIAL[:j INDUSTRIAL E]RURAL TYPE OF BUSINESS 0 RETAIL FUEL STATION <br /> Joe. m 6® Par ky Q Co L. E]RESIDENTIAOTHER [DFARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> N (bl) 40-3151 <br /> REGIONAL BOA a a'I, PHONE <br /> y 11) OUANTITY LOST <br /> ❑ UNKNOWN <br /> H <br /> (2) ❑ <br /> UNKNOWN <br /> DI6TE DISCOVERED FEW DI�OVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE PTORIN3 NUISANCE coNDrrIONS <br /> w <br /> .1 5M 1 o 3 .1 OY Y ❑ TANK TEST ❑ TAN(REMOVAL CK OTHER UM►a !7i IG a'� <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> W M M D Y Y <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPIT ❑ CHANGE PROCEDURE <br /> p E] YES ❑ NO IF YES,DATE M M D Y Y ❑ OTHER <br /> SOURCE OF DISCHARGE TANKS ONLYOCAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK X UNKNOWN C GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREIFALURE <br /> ❑ PIPING LEAK AGE S YRS ❑ STEEL ❑ CORROSION ❑ UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w CHECK ONE ONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> i CHECK ONE ONLY <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> H ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED DQ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTIONS)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> 2 ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE 6 TREAT(ET) ❑ PUMP 6 TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> HSC 05(4AM <br />