Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 9 � i HEREBY canFYTHAT is HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> YES NO j__ YES NO DISTRIBUTION SHOWN CN:THE INSTRUCTION SHEET ON THE SACK PAGE OFTHIS FORM. <br /> REPORT DATECASE s <br /> MA cI r SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> co <br /> i ) <br /> REPRESENTING REGIONAL BOARD COMPANY OR AGENCY NAME <br /> F ® OWNERIOPERATOR <br /> RLOCAL AGENCY Q OTHER <br /> ADDRESS <br /> STREET CIT/ STATE zip <br /> Lu NAME TPERSON PHONE <br /> to <br /> t yy <br /> cn <br /> UNKNOWN i 1 <br /> O <br /> N as ADDRESS <br /> Lu <br /> STREET CITY STATE ZIP <br /> OPERATOR PHONE <br /> FACILITY NAME(tiF APPLICABLE) / } <br /> z <br /> 0 i ! <br /> 4 ADDRESS <br /> U <br /> O <br /> w <br /> w STREET crrr COUNTY ZIP <br /> CROSS STREET <br /> LOCALAGENCY AGENCY'.WE CONTACTPERSON PHONE <br /> ze iti <br /> ww <br /> 4 <br /> w w REGIONAL BOARD PHONE <br /> 0 <br /> CL <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> v� <br /> Z UNKNOWN <br /> m z (2) <br /> cn ❑ UNKNOWN <br /> DATE DISCOVEREDHOW'DTt "/ RED INVENTORY CONTROL SUBSURFACE MONITORING E] NUISANCE CONDITIONS <br /> Lu µl ul oI o r r Q "�' TEST TANK REMOVAL 0 OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN <br /> CONTENTS E:]CLOSE TANK&REMOVE REPAIR PIPING <br /> M o n r <br /> l 0 Lu <br /> P HAS DISCHARGE BEEN STOPPED 7 REPAIR TANK Q CLOSE TANK S FILL IN PLACE p CHANGE PROCEDURE <br /> o YES [—] NO IF YES,DATE MI T o� oI rI r 0 REPLACE TANK I� OTHER <br /> SOURCE OF DISCHARGE CAUSES) <br /> nu <br /> TANK LEAK ❑ UNKNOYM OVERFILL RUPTURE/FAILURE SPILL <br /> a <br /> w ca PIPING LEAK ❑ OTHER Q CORROSION UNKNOWN Q OTHER <br /> w w CHECK ONE ONLY <br /> N IZ <br /> v UNDETERMINED SOIL ONLY GROUNDWATER DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> E NO ACTION TAKEN Q PRELIYZIARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> Lu jR <br /> =1 Q LEAK BEING CONFIRMED PR2 IWNARY SITE ASSESSMENT UNDERWAY POST CLEANUP MON ITORINGINPROGRESS <br /> U y r__j REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) 0 ENHANCED BIODEGRADATION(IT) <br /> IME SWA KM DUALM <br /> a z <br /> o O I7 CAP SITE(CD) ❑ EXCAVATE x TREAT(ET) PUMP a TREAT GROUNDWATER(GT)Q REPLACE SUPPLY(RS) <br /> Lu <br /> Lu a CONTAINMENT BARRIER(CB) F7 MACTION REOUIRED(NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> 1 <br /> VACUUM EXTRACT(VE) C OTHER(OT) <br /> z <br /> 0 <br /> O <br /> v <br /> HSC O5(8W <br />