UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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go- u3b UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERG901Y SERVICES FOR LOCAL AGENCY USE ONLY ❑ YES Ep/NO REPORTBEEN FILED 7 YES ❑ NO I HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.1 OF REPORT DATE CABER THE-LIFf�LTH�NO SAFTY CIL, ,/ 01 3M v v Si DATE NAME OF INDIVIDUAL FLING REPORT PHONE SIGNATIJRE es E A. ) 6Ve-3 D REPRESENTING 0 OWNEWOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME p LOCAL AGENCY ❑ OTHER �f.J ✓ [IIr� )9"`c a ADCrRESS 3 smEE d 1J c Y Are O Fi Z, NAMECONTACT PERSON ( PHONE Bpa '(�� ❑ UNKNOWN i ADDRESS BTREEr N CID' C14 A. IP FACILITY NAME(IF APPY CABLE) OPERATOR PHONE F' [l ADDRESS Jsneer ^�N cm AJ ceuKry �Q P yCROSS STREET++ TYPE OF AREA ❑COMMERCIAL NDUSTRW. ❑RURAL TYPE OF BUSIN ❑ RETAIL FUEL STATION TN US1 ❑RESIDENTIAL ❑OTHER ❑ FARM OTHER r� LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE � N Vo? ) ) �Q-3 OwM AJ rfPQ (CS wH1 REGIONALBDARD I PHONE NAME QUANTITY LOST(G Sj5 / tov (us _ UNKNOWN Z� (2) ❑ uNomm DATE DISCOVERED HDW DISCOVERED ❑ yEMOpy CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS w ❑ TANK TEST TANK REMOVAL ❑ OTHER D D Y Y DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) /OSE TANK M o D y y UNKNOWN ❑ REMOVECONTENTS ❑ REPLACETANK M ,�✓U,(CL HAS DISCHARGE BEEN STOPPED T ❑ REPAIRTANK ❑ REPAIRPP14G ❑ CHANGE PROCEDURE S YES ❑ NO FYES,DATE Ou �2, 313v OY 0 OTHER u� SOURCE OF DISCHARGE TANKS ONLYCAPACITY MATERIAL CAUSE(S) O ❑ TANK LEAK UNKNOWN SOS GAL. ❑ F ERGLASS ❑ OVERFILL ❑ TUREIFAILURE ❑ PIPING LEAK AGE rlWk YRS TEEL ❑ CORROSION NOU N ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER iy CHECK ONE ONLY ❑ UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) r CHECKON�ONLY ❑ z w as SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS E7] SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) U'D 0 NOACTIONTAKEN ❑ POST CLEANUP MONITORING N PROGRESS ❑ NO FUNDS AVAILABLETOPROCEED ❑ EVALUATING CLEANUP ALTERNATIVES CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) 3 z ❑ CAP SITE(CD) ❑ EXCAVATE A DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) i ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE 6 TREAT(ET) ❑ PUMP a TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REOUIRED(NA) ❑ OTHER(On aA k S-0/ O 9-141K " t7toCom Tsn/ /ON Qs uiriT�7D "7 7� q// M�✓a / c�/wfeY/ P��PS HSC (4W)