Laserfiche WebLink
9r-u8� <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES 2TIONSHOWN CAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑VES HO ❑ VES �NO <br /> ON THE STRUCTION SHEET 0 PAGE OFTHI$f017MREPORT DATE CASEOJTMl DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGN RE <br /> W REPRES TING ❑ OWNEROPERATOR ❑ REGIDNALBOARO COMPANY OR AGENCY NAMES/J <br /> S �OCALAGENCY a OTHER J /&) <br /> wn <br /> ADDRESS <br /> ) �/,.� ff..GG. <br /> . u- • arg zoo arREEr =Y <br /> J NAME CONTACT PERSON <br /> �� � (PHH.AO!/NEE <br /> Z `W ❑ <br /> UNKNOWN <br /> 'L, `� C <br /> 0 g ADDRESS <br /> a O- BN '5'? / STREET oRr�iLrt a o ST-TE <br /> FACILITY NAME(IFAPPLICABLE) OPERATOR PHONE <br /> < ADORESS <br /> COUNTS. <br /> g CROSS STREET <br /> .L/Al(20 /V <br /> g LOCAL AGENCY AGENCY NAME CONTACT PERSON <br /> PHONE /J <br /> REGIONAL BOARD PHONE <br /> __ C'� ,urc� ✓�z LLs /c�c�. �O6Gs 6. c 9,14) 36i �6aa <br /> uy (+1 NAME QUANTITY LOST(GALLONS) <br /> S /t /LCLL �NOWN <br /> N <br /> ❑ UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> D p / r ❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> wD UNKNOWN [:)REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&F&1 IN PLACE ❑CHANGE PROCEDURE <br /> ❑ YES lvl< IF YES.DATE J J Yi r ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGECAUSE(S) <br /> 1 ❑ TANK LEAK dNKNOWN ❑ OVERFILL ❑ RUPTURF/FAILURE ❑ SPILL <br /> ����iiii O ❑ PIPING LEAK ❑ OTHER Q CORROSION Q UNKNOWN Q OTHER <br /> w CHECK ONE ONLY �,/ <br /> O ❑ UNDETERMINED LJ✓ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ¢< <br /> F-1NOACTDNTAKEN ❑ F(ELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> U, F-1LEAKSEINGCONFIRI PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTON(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> Ia aw ralaTwq <br /> W 4 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY IRS) <br /> U�j6 ❑ CONTAINMENT 8ARfl1ER(CB) ❑ NO ACTION REWIRED(NA) a TREATMENT AT HOOKUP MU) VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> OL �'a�`1� � ^ e/� mow(!/��•f�(A+�t J��K' % <br /> w ` a.Q ./V+jGSKLq V <br /> 9 <br /> NX Ee IEICN <br />