Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERV FOR LOCAL AGENCY USE ONLY. <br /> YEE AND THAT I HAVE <br /> ❑YES ❑ NO REPORT BEEN FILED? ❑YES r/ NO REEPORTED THS NFORMATIONREBY CERTIFY THAT I AM ATO LOCAL OFFICIALTED S PURSUANT URSUANT TMENT OO SECTION 25180.7 OF <br /> REPORT DATE CASE• KI IHSH NO SAFTY CODE <br /> O u Iu O Y y SIGNEDD DOTE <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGNATURE <br /> c6cle5 "'+ (moi) 3-w0 <br /> REPRESENTING ❑ OWNEWOPERATOR ❑ REGIONALSOARD COMP//ANY OR AGENCY NAME / ,l <br /> IVLOCAL AGENCY ❑ OTHER <br /> ¢ ADDRESS <br /> Gol E. Q Dti S{cck " CRY CA75.2 01 xiv <br /> tI NAME CONTACTPERSON PHONE <br /> HQ o� -6r -fi ❑ uNKNowN obr Mo,.,,C' (za9 ) - 8s <br /> n .71 <br /> ADD <br /> E-1 oprark STREET CITY C HTATE nP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> E ,ue Crs 3 �04 ) 516.2-/moi <br /> ADDRESS <br /> 11/6 E $`r Cm Jca owIffY 12 <br /> 206 <br /> m CROSSSTREET TYPEOFAREA COMMERCIAL ❑NDUSTRIAL❑RURAL TYPEOFBUSINESS <br /> O RETAIL FUEL STATION <br /> ZRESIDENTIAL ❑OTHER ❑ FARM BOTHER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> NG flf( S o,� Pero.'-' <br /> )y REGIONAL BOA PHONE <br /> (1) NAME OUANTOY LOST(GALLONS) <br /> Clem-o1lNe ❑ UwNOvm <br /> ❑ UNKNOWN <br /> OATEDISCOVERED 9-DI <br /> HOW DISCOVERED 0 INVENTORYOONTROL E] O SUBSURFACEmowroRN ❑ NUISANCE CONDITIONS <br /> M D 6 D g-Y y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> ¢ u M D D Y Y UNIQIOWN ❑ REMOVECONTENTS E] REPLACE TANK CLOSE TANK <br /> SMw� 77 (� c <br /> p YES ❑ NO EYES,DATE L.VM 6 u /2 D o D O 11'71 ❑ OTHER TANK ❑ REPAIR PPNO ❑ CHANGE PROCEDURE <br /> u� SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL C USES) <br /> [:] TANK LEAK � UNKNOWN SSO GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RLPTURE*ALURE <br /> K� ❑ PIPING LEAK AGE -.2i�2_ VPS STEEL ❑ CORROSION ZUNKNOWN <br /> ❑ OTHER Q UNKNOWN ❑ OTHER ❑ WILL ❑ OTHER <br /> yw CHECK0 NLY <br /> UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> w¢ ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CL P COMPLETED OR UNNECESSARY) <br /> 80 ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING PROGRESS ❑ NO FUNDS AVAILABLE TOPROCEED ALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE 8 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(In <br /> ❑ CONTAINMENT BARRIER(CB) F-1EXCAVATEB TREAT(" E:] PUMP&TREAT GROUNDWATER(DID, ❑ REPLACE SUPPLY(RSI <br /> ❑ TREATMENT AT HOOKUP(HU) Q NO ACTION REQUIRED(NA) ID--6THER(OT) ,Sell knk.2 <br /> r4l�(erS� otssEsstn1< a .I/ ba t�ulre -lo de+,frkl;AvC ,444 na-furG <br /> r�Tc1-'I V/f CO.wI+SCvlln.w(JdN I OS fAIr4!W jy atl pYaLi u <br /> esc as P.e�I <br />