Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT <br /> REPORT BEENENFILILED? <br /> EMERGENCY HAPSTATEF E ?EMERG SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑YES NO YES ❑ NO I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTDATE :REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25160.7 OF <br /> CASES THE Hp CODE, �'AV <br /> M MP? D Y Y <br /> NAME OF INDIVIDUAL FLING REPORT DATE <br /> PHONE SIG TURF <br /> s ) <br /> REPRE ING ❑ OWNERPOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAM <br /> p LOCALAGENCY F OTHER - <br /> a ADDRESS <br /> NAME <br /> STRE17 S47crt< w! CRY 2Q/ <br /> °1I C IACTPERS0N <br /> ( / PHONE <br /> m y M C T ❑ UNKNOWN Leu N ) g <br /> i ADDRESS <br /> a <br /> D STREETLAW <br /> CRY ffiATE p <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> Nk <br /> ` ADDRESS w -f36 <br /> 0oux B REE _ <br /> pp <br /> q CROSS STREET TYPE AREA O COMMERCIAL ❑ INDUSTRIAL❑RU TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> Orn S'+ flESIOENTIAL Q OTHER O FARM ❑ OTHER <br /> LOCALAGENCY - AGENCY NAME CONTACTPERSON PHONE <br /> N <br /> oz <br /> HI REGIONAL BOARD <br /> Y PHONE <br /> w 111 NAME OUANTITY LOST(GALLONS) <br /> 1. o IJQ a?-oU`WNOWN <br /> (zi <br /> ❑ UNKNOWN <br /> DATEDISCOVEREO HOW DISCOVERED ❑ VENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCEODNDrtgNS <br /> w <br /> M M o Y OY E] TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M o o y Y UNKNOWN ❑ REMOVECONTENTS ❑ REPLACETANK E] CLOSETANK <br /> HAS DISC EBEENSTOPPED? ❑ REPAIRTANK ❑ REPAIR PIPING ❑ CHANGEPROCEDURE <br /> O YES ❑ NO IF YES,DATE M Z o8YI9Y ❑ OTHER <br /> uyi SOURCE OF DISCHARGE TANKS CNLY�CAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN r(7t=> GAL, ❑ FIBERGLASS ❑ OVERFILLPTUREi AILURE <br /> 0 PIPING LEAK AGE 10 YRS STEEL O CORROSION ❑ UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> ww OHECKONEONLY <br /> ❑ UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKONEONLY <br /> 2H <br /> c ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> 8145 ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVALABLE TO PROCEED ❑ EVALUATINOCLEANUPALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> a ❑ CAPSITE(CD) ❑ EICAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE6TREAT(ET) ❑ PUMPb TREAT GROUNDWATER roT) ❑ REPLACE SUPPLY(RS) <br /> ❑ <br /> TREATMENT AT HOOKUP(HU) �f❑ NO ACTION REQUIRED INA) ❑ OTHER(OT) <br /> �j <br /> R Sv. !l°�u r-P[>Pa SDS�Cpn,JcY17//Nd /0T4l <br /> astecor,'� C!// de tryairx./ fe /eM,,jwi.✓e ie va7r rje 17"VI r,)A-...f eP <br /> Ca rl/na�ien� !is I`�u/r -& 4l r�hlsrlx a& P� <br /> xacmlaen <br />