Laserfiche WebLink
q1-1-a 19 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED T I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> F-1YESNO [:] YES 1�0 <br /> DISTRIBUTION SHOWN ON THE jNSTRU TION SHEET ON THE BACK PAGE OF THIS FORM. <br /> REPORT DATE CASE• .�} 3.- I.6.-9� <br /> O M 3 ml v SIGNED f I DATE <br /> NAME OF INDIVDUALFILI REPORT PHONE SIGNATURE <br /> w REPRESENTIAL OWNE PERATOR ❑ REGIONAL BOARD COMPANY OttR�A--GENCVNAME/ / n <br /> ¢ VLOCALAGENCY ❑ OTHER �YY _SOLI. L✓I(AarI. PLL6I(C. I* <br /> it <br /> ¢ ADDRESSL4 t�G � ` �0. C , - �(_ <br /> �5 sTReer c.J".r.lm TDY1 <br /> STATE ZIP <br /> w NAME CONTACT PERSON PHONE (� <br /> i� wU ❑ UNKNOWN C ) N <br /> yADDRE58 .O ` ^ ` 7 G' I� Li►T RSN3 I <br /> P ,{rCJTB (� J�l1 Cm STATe IP <br /> s SET E� <br /> FACILITY NAME QF APPLICABLE) OPERATOR <br /> Cal ( �orn.(A We « (r< ( ) <br /> ADDRESS sem'\ . (9 it f/7 <br /> w <br /> srREEr L l Vcm�P� 1 cm couxry (� IP <br /> m <br /> CROSSSTREET <br /> i LOCAL AGENCY AGENCVN E CONTACT PERSON PHONE <br /> w w REGIONAL BOA fiD , A ' 1 PHONE <br /> w (�) NAME QUANTITY LOST(GALLONS) <br /> U w t S UNKNOWN <br /> a 3 111 <br /> Z <br /> m p <br /> �UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING El NUISANCE CONDITIONS <br /> z <br /> a D $Y Y ❑ TANK TEST ®TANK REMOVAL ❑ OTHER <br /> w W vM <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> irL-r UNKNOWN E]REMOVE CONTENTS CLOSE TANK 6 REMOVE ❑REPAIR PIPING <br /> 4 ul DI Y1HAS DISCHARGE BEEN STOPPED? Y ❑REPAIR TANK ❑CLOSE TANK E FILL IN PUCE ❑CHANGE PROCEDURE <br /> g Q YES ❑ NO IF YES.DATE I C Y <br /> REPLACE TANK ❑OTHER <br /> Q <br /> SOURCE OF DISCHARGE CAUSES) <br /> ¢ ❑ TANKLEAK FR"UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> 0O E] PIPING LEAK ❑ OTHER ❑ CORROSION [IUNKNOWN ❑ OTHER <br /> ww CHECK ONE ONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK EONLY <br /> w [7NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ar ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O m ❑ 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 /> Iaff avairwoETunl <br /> fa 4 ❑ CAP SITE(CO) ❑ EXCAVATE 6 TREAT(ET) ❑ PUMP 8 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RST <br /> wa <br /> ~ F-1CONTAINMENT BARRIER(CB) F-1NO ACTION REQUIRED(NA) F7TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ¢ <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT)❑ <br /> L�� 0. a- : L oca -Y <br /> s <br /> HSC OS ISM% <br />