Laserfiche WebLink
r" <br /> Q <br /> i <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY <br /> REPORT BEEN FILED? 3 BERM.CERTIFY:-T}tAT.,t AM.A.OESK;MATF GOVERNMENT:EMPLOYEE'AND THAT 3 HAVE:. <br /> ❑ YES NO []YES �f l0 REPORTED.; INFOR.MATtOPt TO LOCA! OFI IC. PURSUANT,TO SECTtON'.25t64 MMOR <br /> REPORTOATE CASEm THEHEAITH ODDS: -- <br /> f <br /> i . <br /> ( I Mi /D� �r f r SIGN <br /> I <br /> NAME OF INDIVIDUAL FILING REPORT PHONE / SI <br /> IGNATUR <br /> y�� f <br /> ti AEPRESE G ❑ ❑ COMPANY OR AGS=NCYNAME <br /> w OWNERlQPERATOR REGIONAL BOARD i <br /> ' p LOCAL AGENCY ❑ OTHER S �JC1 ( U��L•; �� L D/S rW/c- <br /> CL <br /> c ADDRESS // C//y <br /> STREET Ab CRr�I �.l/:Ll�'V4-/U1'�' STATE `�/�•t< .� z p <br /> Lu <br /> NAME CONTACTPERSON ''I PHONE <br /> it (/ —5LJ ❑ UNKNOWN <br /> as ADDR S <br /> Lu o F53 <br /> 37'REET `-.-, -CC'�� CRY�' 'I�� STATE 21p <br /> FACILITY NAME(IF APPLICABLE) OPERATOR •.i PHONE <br /> Q 31 <br /> a ADDRESS <br /> s/ STpEET CRY'} •'/ — COUNTY P <br /> y CROSS STREET TYPE OF ❑COMMERCIAL❑INDUSTRIAL❑RURAL TYPE OF BUSINESS RETAIL FUEL STA ON <br /> I RESIDENTIAL ❑OTHER II ❑ FARM OTHER � v <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON ;( PHONE <br /> lu- <br /> aLu REGIONAL✓96ARD (' i IPHONE <br /> SIJ?IL � <br /> �. -GCJ L i?G i1✓' )Jt'D ''�z5c D <br /> CAP ;tJ NAME L i% J QUANTITY LOST r—AL,LONS) <br /> J <br /> M 0 (2) <br /> y J { ❑ UNKNOWN <br /> z DA�T7E DISCOVERED HOW DISCOVERED F7 INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lu <br /> w C� M o o r r TANK TEST [:] TANK REMOVAL ❑ O7HER <br /> DATE DISCHARGE BEGAN / METHOD USED TO STOP DISCHARGE(CHECK ALL THATAPPLY) <br /> u o o r r NNKNOWN E::] REMOVE GONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> p HAS DISCHARGE BEEN STOPPED Z ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> q ❑ YES ❑ NO IFYES.DATE MI M� OTHER ;{ <br /> rw SOURCE OF DISCHARGE TANKS ONLYICAPACI CAUSE(S) <br /> ❑ TANK LEAKE�j UNKNOWN FI S ❑ OVERFILL ❑ -RUPTUREFAILURE <br /> ❑ PIPING LEAK AGE YRS STEEL ❑ CORROSION �NOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> Lu w CHE�ONY CL ERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELTS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY �[ <br /> s�F ❑ SITE INVESTIGATION 1N PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP lNPROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> y ❑ NO ACTION TAKEN [:] POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVJIILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) it <br /> z ❑ CAP SITE(CO) ❑ EXCAVATE A DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> uJ ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE A TREAT(ET) E-1PUMP 5 TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REOUIREO(NA) ER(OT) ' - {�c <br /> FC �/`vC?LI GLtit iN�'C�, �LGc L`L a <br /> z .� <br /> Lu <br /> ) <br /> r <br />