Laserfiche WebLink
()9 - U Z3 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL'AGENCY USE ONLY <br /> ❑ YES � NO REPORT BEEN FILED? ❑ YES ❑ NO I HEREBY CERTIFYTHAT I.HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REFpFIT DATE CASE:1 <br /> �]f u Y 31GwED DATE <br /> NAME OF INDIVIDUAL FILIN ORT PHONE SIGNATURE <br /> AP �qll i zo <br /> REPRESS <br /> r ❑ OWNEROPERATOq ❑ REGIONAL BOARD COMPANYOR AGENCYNAME <br /> g e LOCALAGENCY ❑ OTHER "s-c-#O <br /> ADDRESS /� /♦� -T/ �(/,�� //�� <br /> OSTREET <br /> w NAME � CONTACT PERSON <br /> zit: TO + 160N/ ll,vC ❑ UNKNOWN WILLI" (R1 (P2H0ON1 <br /> E )236- I✓ <br /> 4�)I <br /> a <br /> ADDRESS 515 ( /�LVhON1]W OOD 1 M�Tt C A C A q S�3 <br /> STREET LT' STATE zy <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o TUF-F boy TRA I L.t TUFFBo\/ 11--)C ,3 <br /> `J 1 (Z01) Z `&-?l 6 <br /> g ADDRESS 1 v <br /> �/11 �n1Tt 5T <br /> " l�.J 3c„7� <br /> w 5 RLmo�Dv.� D t�IZ DRY LODMY P <br /> y CROSS STREET <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> �w <br /> � /,6 .is i )(10 l yu <br /> w� <br /> w REGIONAL BOARD PHONE <br /> p) NAME QUANTITY LOST(GALLONS) <br /> yll <br /> 0 <br /> N L <br /> UNKNOWN <br /> 1- GATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 1 u o v Y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOPARGE(CHECK ALL THAT APPLY) <br /> M D V Y U <br /> ❑ UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE E]REPAIR PIPING <br /> j <br /> 8 HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PUKE [7]CHANGE PROCEDURE <br /> ❑ YES ❑ NO IF YES.DATE ud d Y Y ❑REPLACE TANK ❑OTHER <br /> SWRCE ISC14ARGE CAUSE(S) <br /> j TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> a <br /> m O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> w CHECKONEONLY <br /> ❑ UNDETERMINED ❑ SOILONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w� ❑ NOACTIONTAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED lt�pc)LLUTION CHARACTERIZATION <br /> jy ❑ 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 BIODEGRADATION(IT) <br /> �evx Rn oETuq <br /> Q ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(El) ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY IRS) <br /> F-1 WE:]CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> 4 <br /> w <br /> R <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> 92 �( ac crw -A RjjO"oP <br /> z <br /> w <br /> Z <br /> NSC OS Ib30) <br />