Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT <br /> EMERGENCYHAS STATE OFFICE OF EMERGENCY SERVICES FORLOCALAGENCYUSEONLY <br /> U�-.1 <br /> ❑YES NC REPORTBEENFLEUY O I HEREBY CERTIFY THAT I AM A.DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> NO REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION:25180.7 OF <br /> REPORT DATE ^ CASES I HE HEALTH AND SAFTY CODE. <br /> ALD-.1 I O'er �Y --- DATt-. <br /> NAME F INDIVIDUAL FLING REPORT PHONE SIGNAT RE / <br /> � c (.201) <br /> q REPRESENi1N OWNEWOPERATOR Q REGIONALBOARD I COMPANYORAGENLYNAME <br /> p OCAL AGENCY E OTHER U <br /> 6 <br /> ADDRESS _ <br /> 1607 F- /yfJ��z� yszas— <br /> CRY WATE <br /> NAME CONJACTPERSON PHONE <br /> q 2 <br /> UNKNOWN C ('L"// 7-.5j <br /> i ADDRESS ejD 'Sy-y�. 1 6n-- 9r20 <br /> 313 / / , l/ <br /> BTREEf CAY RATE bp <br /> FACILITY NAME(F APPLICABLE) OPEMIDR PHONE <br /> S � (20,i) f3l-4r,&z) <br /> ADDRESS CY7 / �J 9sz 6s- <br /> /3 � �J N »n <br /> yCR;7SSTREET T'PEOFAREA O COMMERCIAL INDUSTRIAL 0 RURAL TVPEOFBUSINESS 0 RETAIL FUEL STATION <br /> wv Q RESIDENTIAL Q OTHER Q FARM XOTHER <br /> AGENCY AGENCY NAME CONT PERSON PHONE <br /> Alk M*4,f 3420 <br /> w REGIONAL BOARD PHONE <br /> /V 0- ( ) <br /> y (71 NAME OUANTRV LOST(GALLONS) <br /> UUWNOWN <br /> (2) <br /> UNKNOWN <br /> i DATE DISCOVERED �J J/+�� J/(�/ HOWT7DIISSCCTOVERED O INVENTORY CONTROL Q SUBSURFACE MONITORING 0 NUISANCE CONDITIONS <br /> M / D LD �/ Y V Y L.J TANK TEST O TANK REMOVAL O OTHER <br /> DATE DISCHARGE BEGAN METHOD TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M u o YKNOWN REMOVE CONTENTS O REPLACE TANK O CLOSETANK <br /> Q pNBEENSTOPPED7 ILJREPAIRTANK REPAIRPPWG CHANGE PROCEDURE <br /> YES a o v Y <br /> OTHER 4-7d <br /> u� SOURCE OF DISCHARGE TANKS ONLYCAPACITY MATERIAL CAUSE(S) <br /> O TANK LEAK E�fUNKNOWN GAL. 1Q FIBER-GLASS OVERFILL O RUPTURErFAILURE <br /> U� O PIPING LEAK AGE YRS CORROSION WN <br /> 0 OTHER NKNOWN O OTHER 0 SPILL Q OTHER <br /> w CHECKONEONLY <br /> 0 UNDETERMINED SOILONLY O GROUNDWATER Ej DRINKING WATER (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKONEONLY <br /> SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) O CLEANUP IN PROGRESS O SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> Q NOACTIONTAKEN [:] POST CLEANUP MONITORING IN PROGRESS O NO FUNDS AVAILABLE TO PROCEED Q EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> CAP SITE(CD) O EXCAVATE&DISPOSE(ED) E::] REMOVE FREE PRODUCT(FP) O ENHANCED BID DEGRADATION(IT) <br /> wF-� CONTAINMENT BARRIER(OB) EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GIT) REPLACE SUPPLY IRS) <br /> 0 TREATMENT AT HOOKUP(HU) Q NO ACTION REQUIRED INN Q OTHER(OT) <br /> —'rtrflw� .Sr�e ASs�xs'snd�r�// �l.e�ru��c� 7� �- �✓rte-- �� <br /> HSC�(4 7> <br />