Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑YES 2r� REPORT BEEN FLED? ❑YES NO REPORTED REBY EH S NFORMATONRTiFY THAT I AM ATOE LOCAL OFFICIALSTED GOVERNMENT <br /> PURSUANT TO SECTION 251807HAVE <br /> OF <br /> REPORTDATECASES THE HEALTH ANDSAFTY CODE i <br /> �( r " <br /> Y � Y SIGNED DATE <br /> NAME Of INDIVIDUAL FILING PORT 1��f) yb c_7 K-1 SIGNATURE <br /> REPRESENTING ❑ OWNEROPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> O Z'LOCAL AGENCY ❑ OTHER <br /> a <br /> a <br /> ADDRESS ,/ I <br /> /a/ <br /> b G /�lizt�Jb 7 S�Cit .G All �'CTE ZIP <br /> NAME CONTACTPERSON PHONE <br /> y rt I ©( O ❑ UNKNOWN 041-1-el) ops) /SaII � (o <br /> a ADDRESS <br /> 3�1D "/Ie- S-5Rlej. �jco ro' co <br /> OL m <br /> M 9ySzn <br /> FACILITY NAME(F APPLICABLE) � OPERATOR PHONE <br /> .fa cr✓ac Si, )a-/J /y/tchae/ ®�j'a/ocJ4 '/D568 <br /> i ADDRUESS7 W X� I em c7 004,' jS Ly b <br /> W s Iry =114TV <br /> IS CROSS STREET TYPE OF AREA ❑COMMERCIAL❑INDUSTRIAL ❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> g - an Jdr II/I�L eo. ��5 N✓J pec��r G 1`I// ( } )ybb 3ysc� <br /> w <br /> REGIONAL ARD PHONE <br /> /®.•� /f��� W -S7 31 <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> (a <br /> ❑ urxNowN <br /> r DATEDISCOVERED Xnv' C� HOWDISCOVERED ❑ INVENTORY CONTROL E::] SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> M �u 2-DI-301 . LY ❑ TANKTEST ❑ TANK REMOVAL ✓❑OTHER sed <br /> DATE DISCHARGE BEGAN 0<KNOWN <br /> USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> I M M D D v Y 0 '"'KNOWN ❑ REMOVECONTENTS E] REPLACE TANK ❑ CLOSETANK <br /> HAS DISCHARGE BEEN STOPPED 9 ❑ REPAIRTANK ❑ REPAIRPFNG ❑ CHANGEPROCEDURE <br /> G ❑ YES [I?T NO FYES,DATE M M D D YJ Y ❑ OTHER <br /> u� SOURCE OF DISCHARGE TANKS ONLYDAPACITY MATERIAL CAUSE(S) <br /> ❑ TANKLEAKUNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREAFALURE <br /> ❑ PIPING LEAK AGE YRS ❑ STEEL ❑ CORROSION ❑ UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w CHECKONEONLY <br /> 01"UNDETERMINIRD, ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKNGWATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CNECKONIONLY <br /> Q SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> �H ❑ NOACTDNTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> S ❑ CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODI=(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> 2 ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE S TREAT(En ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACESUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NOACTIONREOUIRED(NA) ❑ OTHER(01) <br /> ��.tbTy Sle LirKs iI ki, ,efs✓ 7E' c24eJ>'isi�c ` <br /> �' cv.>e�r�nGts�Ioi+ as kc <br /> �✓kms CyT-��y• ,r hTctl is M.06 �� t� .•r �� <br />