Laserfiche WebLink
C� r , <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVK3 FOR LOCAL AGENCY USE ONLY <br /> ❑ YES s-y( Np REPORT BEEN FILED? ❑Y �/�('___ 1:HEREBY CERTIFY THAT'1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> Y2SI_ LCI�^� REPORTED:THIS.INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORTD TE CASE• I HE HEALTH ANO SAM CODE J <br /> M M /Y Y SIGNED )ATE <br /> NAME CFIN/nVIIDUAL FLING REPORT PHONE SIG T RE <br /> n s�y !� ( � <br /> REPRESENTING ❑ OWNERpPERATOR Q REGIONALBOARD ��M�PANY OR AGENCY NAME + <br /> IL ..LOCAL AGENCY E] OTHER {�(J kc- L I - oo7 <br /> ADDRESS <br /> w/ E. pa 2& <br /> CJTV WATE ZP <br /> NAME /q CONTACTPERSON /FZNEE <br /> VV <br /> m� i ❑ UNKNOWN <br /> < ADDRESS <br /> Hwy y 5u racy va,✓ WCC 95 P <br /> OPERATOR PHONE <br /> FACLRY NAME IF APPLICABLE) <br /> M l2a`i Z-Z4 <br /> ADDRESS <br /> ,c 0. llffv'� '� STDc�-7aAJ S.JcaS✓ , 95" <br /> �-y CROSSSTREET TYPE OF AREA ❑COMMERCIAL❑NWSTRVIL XRURAL TYPE OF BUSINESS W RETAIL FUEL STATION <br /> w000sbro O RESIDENTIAL =OTHER_ ❑ FARM ❑ OTHER <br /> LOCALAGENCV AGENCY NAME (ONTACTPERSON PHONE <br /> w L� ( --" ylo - Gb <br /> REGIONAL BOARD PHONE <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> C UNKNOWN <br /> lA <br /> �i ❑ UNKNOWN <br /> i DATEDISOOVERED HOWDISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFAGEmoNITORNG E] NUISANCECONDRIONS <br /> 2 0.19,1 Awl. 'ANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> 3 DATE DISCHARGE BEGAN 1METHH(OD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M o D v Y �+ UNKNOWN X-REMOVE CONTENTS O REPLACETANK ❑ GLOSETANK <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIRTANK O REPAIRPPNG ❑ CHANGE PROCEDURE <br /> p M-YES ❑ NO IFYES.DATE M M DI D %0 Y ❑ OTHER <br /> yk SOURCE OF DISCHARGE TANKS ONLWCAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK ❑ UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL RUPTURE/FAILURE <br /> �PIPINGLEAK AGE YRS STEEL ❑ CORROSION 4❑' UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> ywy� CHECKONEONLY <br /> KZ� [>Z1,­UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> k CHECK ONE ONLY <br /> Q ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS 0 SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> 2S� ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> o ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(In <br /> 2K� ❑ CONTAINMENT BARRIER(CS) O EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GID ❑ REPLACE SUPPLY IRS) <br /> F-1 TREATMENT AT HOOKUP CHU) Q NO ACTION REQUIRED(NA) Q OTHER(OT) <br /> "G��Lx.`- 5'/f� CK)6�o�✓/n�>� t�/L.0 a �..oJi�rrK,�nx_, t`� <br /> O T WN i� 9� aim^ co n� Gl rr irrt �axJ coo /7¢� 12-7 <br /> HSC O5(4S7) <br />