UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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UNDERGROUND STORAGE TANK UNAUTHORfZED RELEASE (LEAK) / CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY REPORT BEEN FILED ? YES NO YES ❑ NO I HEREBY CERTIFY THAT] HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM REPORT DATE CASE>f v^' S --� SIGNED DATE v M r NAME OF INDIVIDUAL F LNG REPORT\1 PHONE SIGNATURE _ Vim- (Tlk Y m w Cc REPRESENTING OWNE PERA E] REGIONAL BOARD COMPANY OR ADEN NA r g [:]LOCAL AGENCY OTHERtwr ADDRESS O �0603 l� STREET 'o(�� ' R CY STATE ZIP w NAME �� CONTACTPERSOt4 PHONE N z �� , UNKNOWN cc 0 < 0 ADDRESS w cr STREET CRY STATE zip FACILITY WKE(IFAPPLIC`BBLLE) OPERATOR PHONE °cO.0 ZN 0 U ADDRESS` Sav, S Lu STREET CITY NW IP in - CROSS STREET 0 LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE (aa') �10� w w w 0 REGIONAL BOARDPHONE Iwo o wUw IY LOST (❑GALLONS) (1) NAME 2 N QJ%\\lkZm UNKNOWN N r(2)z t U v UNKNOWN z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS \ r ❑ TANK TEST ❑ TANK REMOVAL OTHER C US r��/k liJ� \Vi -U J hf M DI o Lv r a m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) 2 tib/ \ �' ❑ UNKNOWN u .1 r ❑ REMOVE CONTENTS [::]CLOSE TANK & REMOVE ❑ REPAIR PIPING w 3 ❑ REPAIR TANK ❑ CLOSE TANK & F LL IN PLACE ❑ CHANGE PROCEDURE HAS DISCHARGE BEEN STOPPED ? f° 'M 1 YES❑ NO IF YES, DATE 0-.1 ❑ REPLACE TANK HER 8 ►q p', r Y ,1 W OOL;;; .0 OF UIJ�r1A 11UC CAUSE(S) j0 < ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE SPILL c v ❑ PIPING LEAK OTHER �'` CORROSION ❑ UNKNOWN HER L)Xr J w CHECK ONE ONLY � f +o--- c4\ O ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY z w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION a ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS v ❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY J CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE E DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) (SFE BACK FOR WTAM—% a60 z ❑ CAP SITE (CO) EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) Lu a AION REO RED (NA) ❑ TREATMENT AT H.00KU HU) ❑ VENT SOIL (VS) F7CONTAINMENT BARRIER (CB) eOTCTH 100 ❑ VACUUM EXTRACT NE ER (OT) C(%1 IA? w S i 4% �� �ou� 0 �