Laserfiche WebLink
o-14&/ <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERV CES FOR LOCAL AGENCY USE ONLY. <br /> REPORT BEEN FILED? <br /> ❑ YES NO ❑ VES NO LHEREBV CERTIFY THAT'6 AM A DESIGNATED GOVERNME T EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFORMATION TO LOCAL FICIALS SUANT TO SECTION 25100.7 OF <br /> REPORT DATE / <br /> CASES 4.:z <br /> � (� THE HEALD�Sg/E�V CODE <br /> u u I y ��✓Y "CPCQ SIGNE��' <br /> NAME OF INDIVIDUAL FILING REPORT E <br /> PHONE SIG TUBE <br /> 11b 3y y <br /> R REPRESENTING ❑ OWNERfOPERATOR- ❑ REGIONALBOARDORAeENCYNAME <br /> pF LOCALAGENCV ❑ OTHER Mr,ti III 1 1_ - <br /> oTq ADDRESS C 7i <br /> Ol it �SZ�I <br /> NAME CONTACT PERSON STATE P <br /> \ L / �C' 'e �) ❑ UNKNOWN 59 <br /> ?HONE 1 <br /> <y ADDRESS y^may/, <br /> 0 STREET o l/IV_ �( o Cm // /�?a-I cV m.TE / 'P°Z <br /> F ITYNAME(IFAP CABLE) C OPERATOR PHONE <br /> O r 4 I <br /> ADDRESt <br /> F7/S �n� S�L X5376 <br /> cm �Cc <br /> r, CROSSSTREETA TVPEOFAREA I'S7T1 COMMERCIAL❑INDUSTRIAL ❑R RAL TY'PEOFSUSINESS F-4(RETAIL FUEL STATION <br /> Ot e/ 4 4 4 v� ❑RESIDENTIAL ,❑OTHER ❑ FARM ❑ OTHER <br /> g LOCAL AGENCYAGENCY NAME CONTACT PERSON PHO <br /> w S n S <br /> ww REGIONAL BOARD / <br /> GV e M �� c A'� PHONE <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> /ZQ� G UNKNOWN <br /> R) ^ �J( <br /> �- /d�'*� ,/ • o l�v e4� UNKNOWN <br /> W DATE DISCOVERED /�] HOW DISCOVERED ❑ INVENTORY CONTROL SUBSU FACE MONITORING ❑ NUISANCE CONDITIONS <br /> QC"u �o ©o Y vy ❑ TANK TEST ❑ TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M N D o Y y UNKNOWN ❑ REMOVEOONTENTS E::] REPLACE TANK ❑ CLOSETANK <br /> p HASDISCHARGE SEENSTOPPED7 c/ ❑ REPAIR TANK El REPAIRPPING ❑ CHANGE PROCEDURE <br /> o YES E_] NO IFYES.DATE u ' Oo may- $ZlOTHER —� <br /> u� SCAJRCE OF DISCHARGE TANKS ONLY)CAPACITY MATERIAL CAUSES) <br /> ❑ TANKLEAK DC UNKNOWN GAL ❑ FIBERGLASS ❑ OVERFILL ��-❑yy�, RUPTUREFALURE <br /> PIPING❑ OTHER <br /> AGE UNKNOWN YRS Q OTHER STEEL ❑ CORROSION IJ<( UNKNOWN <br /> ❑ ❑ SPILL ❑ OTHER <br /> w CHECKONEONLY <br /> F-] UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHE ONE ONLY <br /> ¢< SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVALABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> o ❑ CAP SITE(CD) ❑ EXCAVATE a DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(In <br /> 2YF-1CONTAINMENT BARRIER(CB) O EXCAVATE B TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(BIT) E] REPLACESUPPLY(RS) <br /> Hl ❑ TREATMENTAT/HOOKUP(HI ❑ NO ACTION REOUIRED(NA) �y❑�OTHH�ER-,(•001) / <br /> r If 0(4M7) <br />