UAR/PROP 65 PRE 2019 - Laserfiche WebLink

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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY , HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY ❑ YES ❑ NO REPORT BEEN FILED 9 ❑ YES ❑ NO 1 HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE > DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM: REPORT DATECASE e M M Y SIGNED DATE NAME OF INDIVIDUAL FILING REPORT PHONE ) SIGNATURE m wREPRESENTING F-1 OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME F- p ❑ LOCAL AGENCY ❑ OTHER ui cc ADDRESS STREET CfTY STATE ZIP w NAME CONTACTPERSON PHONE J z ❑ UNKNOWN 2 00 a ADDRESS U) w a[ STREET CITY STATE ZIP FACILITY NAME(IF APPLICABLE) OPERATOR PHONE 1 z0 / < ADDRESS U O Lu STREET CITY COUNTY Lu ZIP CROSS STREET 0 LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE zco �w w U w w REGIONAL BOARD PHONE J U �a / 1 (�) NAME OUANTITY LOST(GALLONS) Lu W Z ❑ J UNKNOWN m> (2) z_ ❑ UNKNOWN z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS w M1 MI DI DI Yl Y ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER < DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) m ❑ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING cc Lu M M 0 D Y Y 0 HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE U cn ❑ YES ❑ NO IF YES,DATEM MI D D V Y ❑REPLACE TANK E] OTHER U p SOURCE OF DISCHARGE CAUSE(S) w j< ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTUREJFAILURE ❑ SPILL U)U ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER Lu w CHECK ONE ONLY hd U ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION w cr ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY E:] POST CLEANUP MONITORING IN PROGRESS U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) J z F_] (SEE HACK FOR DEf ALS) a CAP SITE(CD) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) 00 wF- w 0 ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) o ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) m z z Lu 0 O U HSC 05(850)