HomeMy WebLinkAbout[Untitled]_22-584 .
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) ! CONTAMINATION SITE REPORT
EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICE s
REPORT BEEN FILED ?
❑ YES NO
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:(#�ERir$1 C1rFiT iF! NA3; isAlso ;:AUS�GAiITQ!AAtEI'Ei1PC?Y ANR'[FAf;;HAI(:
❑ YES NO
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REPORT DATE
CASE #.
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NAME OF INDIVIDUAL FILING REPORT
PHONE
SIGNATURE
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REPRESENTING �❑ OWNESIOPERATOR ❑ REGIONAL BOARD
COMPANY OR AGENCY NAME
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ADDRESS �''} -7 t. f m ! i Si, ! .4 3j ®O 9 4j4zk -S• :e_iCi (14 � ,.7 � 1.
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sTREEr t csrY STATE ZIP
NAME
CONTACT PERSON
PHONES;
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❑ UNKNOWN
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ADDRESS L' /� k"" 1 Y /y �i 4 ` `-� Q,�{ ^� 1✓`S�• -P, t - :, ,. ;. ' "'7
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. FACILIIY NAME (IF, APPUCABLE)-- •- - ----- - • -_._.. _.�_w : ___ _ __OPEi2ATOR.
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ADDRESS ��•. Pf' .0— r Cc.. 124S r3A kr-- r4R, c4
•J'1lEG{ VII( Mar. /w. Ap
CROSS STREET' - -
TYPE OF AREA ❑ COMMERCIAL INDUSTRIAL ❑ RURAL
TYPE OF BUSINESS RETAIL FUEL STATION
�G L
❑ RESIDENTIAL ❑ OTHER
❑ FARM OTHER
LOCAL AGENCY AGENCY NAME
CONTACT PERSON
PHONE
Lm
LuREGIONAL
R
BOARD
-
PHONE
(�) NAME QUANTITY LOST (GALLONS)
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0
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❑ UNKNOWN
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DATE DISCOVERED
HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS
'7 ml 0.1 -7D eY 6) Y
❑ TANK TEST TANK REMOVAL ❑ OTHER
DATE DISCHARGE BEGAN
METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY)
UNKNOWN
M ht Q D Y Y
❑ REMOVE CONTENTS. ❑ REPLACE TANK F-1 CLOSE TANK
W
❑ REPAIR TANK i ❑ REPAIR PIPING CHANGE PROCEDURE
HAS DISCHARGE BEEN STOPPED ?
YES [],N0 IFYES,DATE .1 *7MI QI Q • oY Y
❑ OTHER �< e t)n a V� ` 2, Ic
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I SOURCE OF DISCHARGE
TANKS ONLYJCAPACITY MATERIAL.
CAUSE(S)
D
❑ TANK LEAK UNKNOWN
GAL. ❑ FIBERGLASS
El OVERFILL- F7 RUPTUREIFAILURE
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❑ PIPING LEAK
AGE YRS � STEEL
i
O ! UNKNOWN
CORROSION
❑ fit
❑ OTHER -
❑ UNKNOWN ❑ OTHER
❑ SPILL ❑ OTHER
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CHE ONE ONLY - •
UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED)
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CH EC ONE ONLY
SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑� CLEANUP IN PROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY)
.0 N
F7 NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED EVALUATING CLEANUP ALTERNATIVES
CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS)
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REMOVE FREE PRODUCT ❑ BIO DEGRADATION (IT)
F7 CAP CAP SITE (CD) EXCAVATE &DISPOSE (ED) ❑ CT (FP) ENHANCED ,
❑ CONTAINMENT BARRIER (CB) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS)
TREATMENT AT HOOKUP (HU) ❑ NO ACTION REQUIRED (NA) ❑ OTHER (OT)
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