Laserfiche WebLink
qla& <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) C/ONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL'AGENCY USE ONLY <br /> [_1 YES ❑ NO REPORT BEEN FILED 7 El YES ❑ NO 1 HEREBY CERTIFY THAT I.HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE CASE <br /> 1t -1 64 r SIGNED DATE <br /> NAME OF INDIVIDUAL FILI REPORT PHONE SIGNATURE <br /> 1'►Loc ace arta ( )�g'3` V1 <br /> w REPRESENTI ❑ OWNERANP RATOR ❑ REGIONAL BOARD COMPANY OR 1AG1E-NCY NAME <br /> ¢ LOCAL AGENCY ❑ OTHER �K(D(IC�}Ca(TY�SICUI CeS VI fOnm I ("YC41 <br /> S54 <br /> ADDRESS i3aX S+o�k-P <br /> CIA- Is-oa�MREE G Y STATE <br /> w NAyMyE� 1 n -. 1- CONTACT PERSON PHONE nr <br /> �0, I�LL.Y��� ❑ UNKNOWN <br /> a a ADDRESS <br /> Ph rdpa r-F ink 5-ta)c f<4vy N CA- °I S 2a,6 <br /> FACILITY NAME(IF APPLICABLE) (� OPERATOR PHONE <br /> iP%o ka�J K.ti�i�fr l <br /> ADDRESS <br /> w 4 y S q A-+ r fa r W <br /> y CROSS STREET <br /> Z <br /> LOCALAGENCY ` W u AGENCY XAME NTACT PERSON I r(� PHONE <br /> umg) <br /> aREGIONAL Z QALBOA /PHONE <br /> VV 1 <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> w O <br /> <i �� UNKNOWN <br /> UNKNOWN <br /> i DATE DISCOVERED ��QQ HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> O M U r r ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> wM o o r r <br /> UNKNOWN ❑REMOVE CONTENTSLOSE TANK6 REMOVE ❑REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> S2 YES ❑ NO IF YES.DATE M D r r E::]REPLACE TANK ❑ OTHER <br /> UR(((CE OF DISCHARGE M CAUSE(S) <br /> ¢j TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> w O PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> ywa CHECK ONE ONLY <br /> O UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> HECKONEONLY <br /> wZ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> Iat ara�rwmusl <br /> a ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> 00 <br /> wr <br /> wa ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION flE0U1RED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> i 4-oC�0/LTA-YY�I vvc d cL,4v- JV0.$e_ a7� S"^ taeA <br /> w �/ <br /> g <br /> Nsc lx lasq <br />