UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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9z/ t» 9 UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY ❑ YES KNO REPORT BEEN FILED 7 ❑YES ❑ NO I HEREBY CERTIFYTHATI HAVE DISTRISUT D THIS INFORMATION ACCORDING TO THE DISTR/IBUTION SHOWN ON THE niNSTRUCT SHEET ON THE K PAGE OF THIS FORM REPORT DATE CASES z,C/ M T r SIGNED PATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE , REPRESENTING ❑ OWNER/OPERATOR REGIONAL BOARD COMPANY OR AGENCY NAME rV S LOCAL AGENCY ❑ OTHER SA'N iM1 1r4 ¢ ADDRESSCITY ZIP j NAME CONTACTPERSON PHONE Z, 2 S u b Ur 6 UNKNOWN �� I�'1 1r{ri�j J d< ADDRESS IJ Z 1q� f Z 1:: . 4 �-/ em srntT N FACILITY NAME(IF APPLICABLE) ipALI OPERATOR PHONE Lt b ti r b Pry ( 1 a ADDRESS w 2 3 ,010,/ 3 REST S. GGA %�,s-,J T1Y �s P —y CROSS STREET 1� g LOCAL AGENCYelk AGENCY NAME CONTACT PERSON PHONE SAM 0. L41 w ( , QREGION&BOARD PHONE W A� ( 1 I Y QUANTITY LOST(GALLONS) Xw 1p' 1f�ry ,, A�,�p 0 1 e, r V Co i— E � ❑ UNKNOWN i (� m ❑ UNKNOWN i DATE DISCOVEREDHOW DISCOVERED E] INVENTORY CONTROL ❑ SUBSURFACE MONITORING O NUISANCE CONDITIONS x u I o �r r ❑ TANKTEST TANKREMOVAL ❑ OTHER TE DISCHARGE BEGAN r r ❑ UNKNOWN M�HOD USED TO STOP REMOVE CONTENTS ISCHAR E(CHECK ALL THAT CLOSE TANK REMOVE PLY) ❑ ❑REPAIR PIPING p HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK O CLOSE TANK&FILL IN PLACE O CHANGE PROCEDURE o ❑ YES ❑ NO IF YES,DATE u o v r ❑REPLACE TANK ❑OTHER SOURCE OF DISCHARGE 1 CAUSE(S) ¢ ❑ TANK LEAK Y I UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL HO F-1PIPING LEAK OTHER ❑ CORROSION UNKNOWN ❑ OTHER wi CHECKONEONLY ❑ UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY Z ❑ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERFLATION �y LEAK BEING CONFIRMED F-1PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY (� CHECK APPROPRIATE ACTON(S) O EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) I�aw roloE'rN81 zo F-1CAPSITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMPS TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) " ?Q ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED CNA) ❑ TREATMENTATHOOKUP(HU) ❑ VENT SOIL(VS) ❑ VACUUM EXTRACT(m OTHE 0T1 SOD 1 7 r�-o10- 17-IX , f2�rye S i�e as SS�se eT-- W. LCA 6� r�s� u I �v c� rwihNi fhe t� u� w�cQ -e x ri�z9+�tc�Jg7i aS �' J 4PY �e_ a ro r, fac es .