Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVIC <br />REPORT BEEN FILED? <br />RGENCY /NO <br />FOR LOCAL AGENCY USE ONLY <br />I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br />YES L�1/ YES NO <br />DIS IBUON SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FOR <br />9 /. + /t0& v <br />REPORT DATE <br />CASE• <br />Y v <br />rGgEo 1 DATE <br />N ME OF INDIVIDUAL FI NG REPORT <br />PHONE <br />SIGNATURE <br />w �� <br />Y <br />m <br />w <br />REPRESE TING ❑ OWNERIOPERATOR E:] REGIONAL BOARD <br />ANY OR TAGE AME <br />S <br />LOCAL AGENCY ❑ OTHER <br />GMM ZbOL <br />a <br />ADDREE'SYS <br />STREET BTATE <br />w <br />¢_Y`'L <br />N ' <br />�j /h,C� ❑ UNKNOWN <br />N <br />CONTACrERSON PHONE <br />Ona <br />y d <br />2 <br />ADDRESS <br />6 9 <br />�[�)y)� yam//�,%T <br />STgEEf �/V�V�� ./ CITY BTATE Y <br />FACIL E(IF APPLICABLE) <br />OPERATOR PHONE <br />ADDRESS <br />O <br />9TgEE! CITY I <br />w <br />y <br />CRO REET <br />s �-- <br />O <br />LAGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />=w <br />w <br />Sv � S.J. <br />cod 613 <br />w. <br />REGIONAL BOARD <br />PHONE <br />y <br />O <br />(0) NAME QUANTITY LOST (GALLON ) <br />Z <br />a <br />UNKNOWN <br />D JYU <br />i <br />(2) <br />m <br />❑ UNKNOWN <br />z <br />DATE DISCOVERED <br />HOW DISCOVERED ❑ 1 TORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />❑ TANK TEST TANK REMOVAL ❑ OTHER <br />u u o y y <br />a <br />i <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />UNKNOWN <br />E] REMOVE CONTENTS EZZLOSE TANK6 REMOVE ❑ REPAIR PIPING <br />HAS DIS RGE BEEN STOPPED? <br />❑ REPAIR TANK ❑CLOSE TANK 8 FILL IN PUCE ❑ CHANGE PROCEDURE <br />o <br />YES ❑ NO IFYES. DATE <br />❑REPLACE TANK E:] OTHER <br />u r <br />r <br />SOURCE OF DISCHARGECAUSES) <br />¢ <br />❑ TANKLEAKkg UNKNOWN <br />❑ OVERFILL ❑ RUPTURHFAILURE ❑ SPILL <br />a <br />mO <br />❑ PIPING LEAK ❑ OTHER <br />❑ CORROSIONUNKNOWN ❑ OTHER <br />w w <br />CHECK ONLY <br />UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />z� <br />❑ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />�y <br />LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />O <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTION(S) ❑ EXGAVATEBDISPOSE(ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCEDSIODEGRADATIONRT) <br />o O <br />IaH w,RrwoE•iva <br />❑ CAP SITE (CD) ❑ EXCAVATE 8 TREAT (ET) ❑ PUMP& TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />~ <br />wa <br />❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENTSOIL(VS) <br />❑ VACUUM EXTRACT (VE) ❑ OTHER(OT) <br />T s �O <br />w <br />/ <br />�wi� <br />I <br />