UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY:USE ONLY ❑ YES No REPORT BEEN FILED 7 ❑YES ))p 1}IEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT K,.HAVE: D REPORTED THIS INFORMATION TO LOCAL OFFICIALS:PURSUANT TO SECTION 25180.7 OF: REPORT DATE CASE X E HEN TH AND CoSit nv 0M M Z 5 D N tC TE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE qvl, REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME Cc LOCAL AGENCY ❑ OTHER SGy �]uq ;� L a Ge I �� O ✓� tr ADDRESS Jv STREET CITY AT ZIP `N(AME`j TNTACTPERSON PHONE � 7� I\/\ -' l-vo—tV5 11� � ❑ UNKNOWN �\r�T lD 1 Aw J ( () ��6(I a co n ADDRESS C ( �p \ i L ('`'{'�•'Q'� STREET "1„� IP STATE p FACILITY `NAME(IF APPLICCABBLE) OPERATOR �` PHONE 6 7✓ \ 40.��t \ ,I.w4.rS (�\G.�'� poil_ 1 J `1�h.a (2;9) QC It Y63 FU ADDRE�S C STREET y�` IP N CROSS STREET TYPE OF AREA ❑COMMERCIAL �K INDUSTRIAL ❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION �oW,c'C� ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER LOCAL AGENCY AGENCY NAME CONTACT PERSON rn PHONE z w Sa.. 5.94 L o a�� is�v2� �,,:� w REGIONAL BOARD PHONE 2 C-eiAv [�f (r,((-) 9 G f- � 0 (1) j (\ NAME QUANTITY LOST(GALLONS) \ L-27 UNKNOWN O (2) w� 1 �•�✓ol•t✓•^.� C"� �c C�.v��a.� UNKNOWN Lu DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS M J M D D v y ❑ TANK TEST TANK REMOVAL ❑ OTHER DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) W M M D .1 y 11 UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK EVCLOSE TANK HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING CHANGE PROCEDURE YES 0 NO IF YES,DATE q M (.1 (, D FYI (—Y ❑ OTHER LLJ V) SOURCE OF DISCHARGE TANKS'ONLY/CAPACITY- MATERIAL CAUSE(S) xz ❑ TANK LEAK M UNKNOWN `" y GAL. ❑ FIBERGLASS ❑ OVERFILL {❑. RUPTURE/FAILURE L ❑ PIPING LEAK AGE YRS STEEL ❑ CORROSION UNKNOWN ❑ OTHER UNKNOWN OTHER ❑ SPILL 0 OTHER LU w CHECK ONE ONLY v ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) ~ CHECK ONE ONLY zfn Q a ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) 0 CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) Cc U N ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) z ❑ CAP SITE(CD) 0 EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) 00 L0 CONTAINMENT BARRIER(CB) 0 EXCAVATE&TREAT(ET) 0 PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) 0 TREATMENT ATHOOKUP(HU) 1 ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) F Joh CO\/l` C1.��..�1+�4 Tn Y'L.�a• CI. (�vv i� k ./`Q+n-JVD..` ( �� y �- w � HSC 05µ/B7)