Laserfiche WebLink
03- u.oG <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> YESNO REPORT BEEN FILED 7 0 VES O NO 1 HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING 70714E <br /> O <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. <br /> REPORT DATE �y CASES <br /> SIGNED DATE <br /> NAME'OF INDIVIDUAL REPORT HONE SIGNAjURE <br /> D nabm ) �.$Lfw W <br /> w REPRES NTING O OWNER/OPERATOR Q REGIONAL BOARD ``COMPANY OR AGENCY NAME <br /> SLOCAL AGENCY OTHER ..�`lh� n b EY►vircn"�'•' -1 •, <br /> ADDRESS <br /> 3plf Wtibcr �hvl,. STATE / "V21P <br /> J NAME G G S CONTACTPERSON PHONE <br /> Q V#h �-1o1 enjjC.r rjS UNKNOWN Davi4 AiwAkr ( )qio5. 3424 <br /> vOai n ADDRESS �� 6b (,��^ <br /> O w• 4.� � CIiY TATE iP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> Va+�co TrLtLk Pla2�i Tha dda4c. W soc k i (Zoq) ,08 <br /> a ADDRESS (;zDI <br /> w <br /> 1 f�33 <br /> vv. 4V1 E, WN DRr <br /> y CROSS STREET ( •, <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE ) <br /> w-I &wirllxi <br /> vn* AIW Air +G ( uhf) 4��s• ds <br /> w w REGIONAL BOAWO PHONE <br /> 41LA1 &u—Jnrl (91ly)2ss•3115 <br /> w (�) NAME QUANTITY LOST(GALLONS) <br /> i w UNKNOWN <br /> a0 <br /> mo> <br /> z_ <br /> m � UNKNOWN <br /> F. DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL O SUBSURFACE MONITORING E] NUISANCE CONDITIONS <br /> M <br /> z <br /> 3 J 3 O 3 ❑ TANK TEST TANK REMOVAL OTHER I 1 Y 1r <br /> F w D D v <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a2r UNKNOWN O REMOVE CONTENTS E7]CLOSE TANK B REMOVE REPAIR PIPING <br /> W M D D <br /> i 11 Yl <br /> HAS DISCHARGE BEEN STOPPED 7 REPAIR TANK O CLOSE TANK 8 FILL IN PUKE 0 CHANGE PROCEDURE <br /> o O VES O NO IF YES,DATE <br /> ml Ml DI Y Y O REPLACE TANK O OTHER <br /> p SOURCE OF DISCHARGE � CAUSES) <br /> ¢j 0 TANK LEAK X UNKNOWN OVERFILL O RUPTURE/FAILURE O SPILL <br /> 00 O PIPING LEAK O OTHER CORROSION UNKNOWN O OTHER <br /> w w CHECK ONE ONLY <br /> O UNDETERMINED SOIL ONLY GROUNDWATER E�] DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w� NO ACTION TAKEN Q PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED O POLLUTION CHARACTERIZATION <br /> by LEAK BEING CONFIRMED Q PRELIMINARY SITE ASSESSMENT UNDERWAY a POST CLEANUP MONITORING IN PROGRESS <br /> O REMEDIATION PLAN Q CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) O EXCAVATE&DISPOSE(ED) Q REMOVE FREE PRODUCT(FP) O ENHANCED BIO DEGRADATION(in <br /> 1�Arx rrn�T�•AI <br /> az <br /> 00 O CAP SITE(CD) O EXCAVATE 8 TREAT(ET) O PUMP b TREAT GROUNDWATER(GT)O REPLACE SUPPLY(RS) <br /> w� <br /> w a CONTAINMENT BARRIER(CB) NO ACTION REQUIRED INA) a TREATMENT AT HOOKUP(HU) O VENT SOIL(VS) <br /> ¢ VACUUM EXTRACT(VE) O OTHER(0-0 <br /> N <br /> z <br /> Z <br /> W <br /> f <br /> Q <br /> U <br /> HSC m(&Sm <br />