Laserfiche WebLink
• <br />0 9j- u i1 b <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OF RCE OF EMERGENCY SERVICES <br />FOR LOCAL AGENCY USE ONLY <br />REPORT BEEN FILED ` VES ❑ NO <br />YES NO <br />❑ ❑ <br />1 HEREBY CERTIFYTHAT HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br />DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. <br />- // �._Gz '7 <br />/ % 4•- <br />REPORT DATED / <br />CASE 9 <br />lG <br />r <br />SIGNED DATE <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE <br />m <br />w <br />REPRESENTING ❑ OWNER/OPERATOR ❑ REGIO BOARDCOMPANY OR AGENCY NAME /- <br />S <br />c <br />S <br />LOCALAGENCY ❑ OTHER lA G1V W� <br />m <br />` �7 <br />ADDRESS f�J) <br />C\ J LZIPP!/ <br />(/,/iy�\�� <br />/j �J�/� <br />0 1� (/ /sw+EEf CT:�� 3��TE • — <br />j <br />NAME g <br />❑ UNKNOWN <br />CONTACT PERSON / <br />,P✓HJO�NE <br />yu <br />w <br />ADDRESS /� -7 3 y <br />a <br />a <br />` 0 ( 3T EEf clT vim' srATE iP <br />FACILITY NAME (IF APPLICABLE) <br />OPERA OR PHONE <br />o <br />H -V LL Q <br />saPK <br />tj 0 <br />ADDRESS VQ <br />2a neo s // C� �um" 7k <br />w <br />w <br />CROSS STREET <br />Lox <br />i m <br />LOCALAGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE /-7 <br />A-11� <br />w <br />wwREGIONAL <br />s_ < <br />BOARD <br />G ✓ Gg <br />PHON <br />(9 361-s60, <br />m <br />()) NAME QUANTITY LOST (GALLONS) <br />Zw <br />I �V�� rO/ /I. �O ivS ❑ UNKNOWN <br />C/�I ��, ���///���/// <br />m i <br />(Z) <br />y <br />❑ UNKNOWN <br />i <br />DATE DISCOVERED <br />HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />❑ TANKTEST TAN `V OTHER <br />a <br />m <br />DATE DISCHARGE BEGAN <br />MET O USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br />❑ UNKNOWN <br />❑ REMOVE CONTENTS ❑ CLOSE TANK & REMOVE ❑ REPAIR PIPING <br />r <br />MI Ml DI 01 yl i <br />❑ REPAIR TANK ❑ CLOSE TANK& FILL IN PLACE ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED? <br />o <br />❑ YES ❑ NO IF VES, DATEM M o v <br />r ❑ REPLACE TANK ❑ OTHER <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />¢ <br />TANKEAK ❑ UNKNOWN <br />❑ OVERFILL ❑ RUPTUREFAILURE ❑ SPILL <br />a <br />m0F-1PIPING <br />LEAK F-1OTHER <br />❑ CORROSION UNKNOWN E::]OTHER <br />yww <br />CHECK ONE ONLY <br />O <br />UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />w <br />❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />m <br />EAR BEINGCONIRMED ❑ PRELIMINARY ASSESSMENTT CLEANUP <br />ORING IN PROGRESSRDDOAF❑CA <br />OE <br />v <br />EOMPETED OR UNNECESSARY) CLANUPNOERWAV <br />CLOSD (C ANP <br />O <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />ai <br />DO <br />tIEE YLY.fOlI1ET1�5I <br />❑ CAPSITE(CO) ❑ EXCAVATE& TREAT (ET) ❑ PUMP& TREAT GROUNDWATER (GT) REPLACE SUPPLY (RS) <br />¢a <br />❑ CONTAINMENT BARRIER ICE) ❑ NO ACTION REQUIRED INA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENTSOIL(VS) <br />❑ VACUUM EXTRACT(VE) ❑ OTHER(01) <br />�- v,e �� . <br />/voo <br />fuvk G ✓) — G W GiCB % ^/-e <br />