Laserfiche WebLink
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? 1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> El YES d NO YES ❑ NO <br /> DISTRIBUTIONSHOWN ON THE IN TRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE p CASEi !L a e `2T <br /> OM u I O SIGNEDDATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> 4ckrk,, 14A-f- <br /> 0 (209 ) y6p 35'� <br /> IO <br /> REPRESENTING ❑ OWNERPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> S LOCAL AGENCY ❑ OTHER S J <br /> ¢ ADDRESS <br /> yys N- 54, ✓eau S�- <br /> IS $TRE cITY 1J STATE of ZIP <br /> w NAME CONTACT PERSON PHONE <br /> S' ❑ UNKNOWN w V<iJ ) 3-266 p <br /> Q a <br /> ¢n ADDRESS t/��y� <br /> 6622 �r P/g yl✓ CRY c STATE `�2 O <br /> FACILITY NAME(IF APPLICABLE) <br /> Mor;f a lira ers OPERATOR PHONE <br /> -- rr9Y3 -z 6.49 <br /> U ADDRESS W - <br /> W �l� Char/cr 3T cm N COUNTY ,206v zip <br /> I CROSS STREET <br /> Gm,A;-t <br /> LOCALAGENCY AGENCY NAME ODNTACTPERSON PHONE <br /> z¢ ( ) <br /> z0 <br /> w <br /> w� REGIONAL BOARD PHONE <br /> f <br /> m (7) NAME QUANTITY LOST(GAL S) <br /> 0 o I�.'J11I/' <br /> a� GuSal/ar- UNKNOWN �`^\ <br /> C <br /> w -0 ❑ UNKNOWN (Y V <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS Y'V• <br /> uI 2M r D Y Y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> METHOD USED TO STOP <br /> CHARGE <br /> (CHECK ALL THAT <br /> DATE DISCHARGE BEGAN rA UNKNOWN ❑REMOVE CONTENTS ISL t' OSE TANK REMOVE Pte»❑REPAIR PIPING <br /> ly M D Y Y IKI <br /> 8 HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK E FILL IN PLACE ❑CHANGE PROCEDURE <br /> o u YES ❑ NO IFYES,DATEu ZD Y Y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAU S) <br /> ¢j ❑ .TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> a <br /> w Q ❑ PIPINGLEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> ww CHECKONEONLY <br /> ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> rz a+ ❑ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> wZ <br /> �y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SIM ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATEADISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> 1@B.�CRTaIOEiN81 <br /> o� ❑ CAP SITE(CO) ❑ EXCAVATE B TREAT(ET) ❑ PUMPA TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w� <br /> wa ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTON REQUIRED(NA) ❑ TREATMENT AT HOOKUP ❑ VENT SOIL(VS) <br /> ¢ ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> 2 Ap -4-k5 of 5,rA Aaae beep r/cr.ro•� L� °J' 6� Com/ i^'�/�� s r fi/���/y <br /> i /N / .vF M.O�/R('�TyG. {?bAT�� b�N .$'/i✓r4 ��Yl�� A /,J <br /> I-I/Nf I ITR? 'FIL(s �aCl l�1 AaV <br /> NSC OSIA'oW <br />