Laserfiche WebLink
UNDERGROUND ST Q -1 -(A <br /> f A � <br /> STORAGE TANK UNAUTHORIZED RELEASE (LEAK-/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> El YES NO REPORT BEEN FILED 7 FOR LOCAL AGENCY USE ONLY <br /> El YES ❑ NO 1 HEREBY CERTIFY THAT l HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> REPORT DATE CASE s DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> bm m1 Y <br /> NAME OF INDIVIDUAL FfL)N REPORT SIGN <br /> 1` PHONE ATE <br /> >- SI U <br /> Arw� REPRESENTING ❑ OWNERiOPERATOR ❑ REGIONAL BOARD <br /> ¢ COMPANY OR AGENCY NAME <br /> ® LOCAL AGENCY ❑ OTHER <br /> cc ADDRESS e <br /> STREET _ <br /> Lu NAME CfTY ,il- .f.1r J�.� STATE�� <br /> CONTACT PERSON xIP <br /> U3 l� PHONE <br /> ao a ADDRESS ❑ UNKNOWN {m} �r�U <br /> Cc <br /> FACILITY NAME(IF APPLICABLE) STREET - 6C]�-�j <br /> CRM STAT£ <br /> No OPERATOR iv <br /> PHONE <br /> UADDRESS { } <br /> O <br /> F STREET ..{ <br /> n C OSS STREET cRv <br /> PeOUMTY 29. <br /> O LOCALAGENCY <br /> Zw AGENCY NAME CONTACT PERSdN PHONE <br /> wU { <br /> w w REGIONAL BOARD <br /> J C7 <br /> LL a <br /> PHONE <br /> Lu <br /> ra (1) { } <br /> U q NAME QUANTITY LOST(GALLONS) <br /> Z w <br /> p <br /> U)z�(2) UNKNOWN <br /> L- <br /> Lo <br /> DATE DISCOVERED ❑ UNKNOWN <br /> w HOW DISCOVERED ❑ INVENTORY CONTROL �❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> �DISCOVERED <br /> �'�-pl iY Y ❑ TANK TEST „� TANK REMOVAL ❑ OTHER <br /> < DATE OfSCHARGE BEGAN <br /> m <br /> a METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Lu M o Y y ►[]J UNKNOWN ❑REMOVE CONTENTS [R CLOSE TANK&REMOVE REPAIR PIPING <br /> p HAS DISCHARGE BEEN STOPPED? ❑ <br /> cn U REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> YES ❑ NO IF YES,DATE <br /> � M MI I P �❑REPLACE TANK ❑OTHER <br /> O V Y <br /> v w SOURCE OF DISCHARGE CAUSE(S) <br /> 3 ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> y O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> tu wa CHECK ONE ONLY <br /> O ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENTWORKPLANSUBMITTED <br /> Lu� ❑ POLLUTION GHARACTERI7_ATION <br /> D eai ❑ LEAK BEING CONFIRMED ❑ PRELSMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U <br /> REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> IgE fl4GR FOHlIEIM,$) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> J <br /> o p ❑ CAP SITE(CQ) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ¢ ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> Li <br /> 0 <br /> 0 <br /> U <br /> HSC 05 49W <br />