Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORTBEENFLED7 <br /> Q YES ��ND E]YES Icy-Np 1 HEREBY CERTIFY.THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT 1 HAVE <br /> �l REPORTED TH ORMATION TO LOCAL OFFJCIAL f/ANT T SECT N 257007 OF <br /> REPORT DATE RS <br /> CASE:C THE HEAL SAF 1Y ` ' y' / J <br /> M M Y V dyLLL f/� <br /> NAME OF INDIVIDUALFLINGREPERT P NE <br /> SIGNATURE <br /> 0 9) 'V& 5-3y2 — <br /> M REPRESENTING O OWNEROPERATOR O REGK)NALBOARD COMPANYORAGENCY <br /> 'LOCAL AGENCY OTHER �— / 1 /`7,}/ y/��` <br /> S ADDRESS `o Clad 1,/\ Vl� <br /> !(oo ET FAL ,ll�r (J�v( S <br /> NAME CITY <br /> CONTACT PERSON STATE P�rSxJ <br /> //l PHONE <br /> F UNKNOWN ( ) <br /> i <br /> u ADDRESS <br /> ,�frl�/w/` <br /> STREET CT' /l'! S �• \ � <br /> FACILITY NAME IF APPLICABLE) STATE t OPERATOR F <br /> PHONE <br /> o I ) <br /> < ADDRESS _ <br /> tVt�1AcLvy\nlrr LA , CITY <br /> j5 CROSS STREET TYPEOFAREl1cou <br /> 'COMMERCIAL O INDUSTRIAL Q RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> Q RESIDENTIAL ❑OTHER O FARM 0 OTHER <br /> gW LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> w (9/6) —3 0 <br /> ww REGIONAL BOARD <br /> z� Uf C46 (0—"1 IHDNE) <br /> (1) <br /> ^ ( NAM OUANTfIY LOST(GALLONS) <br /> rUNKNOWN <br /> m Jr <br /> UNKNOWN <br /> W DATE DISCOVERED 'FYI <br /> FX)W DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> p <br /> i M J p py y Q TANK TEST TANKREMOVAL OTHER <br /> S DATE DISCHARGE BEGAN ISMETHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w u M o o r v L�1�UNKNOWN E::] REMOVECONTENTS O REPLACETANK CLOSE TANK <br /> Q HAS DISCHARGE BEEN STOPPED 7 REPAIRTANK O REPAIRPPM O CHANGE PROCEDURE <br /> p I Nr�ES4"NO IF YES-DATECW <br /> // OTHER <br /> Qn o o v r <br /> N SOURCE OF DISCHARGE TANKS ONLYiCAPACITY MATERIAL CAUSE(3) <br /> O TANK LEAK ®UNKNOWN 3 ; .y, GAL Q FIBERGLASS O OVERFILL a RUPTURE/FAILURE <br /> PIPING LEAK AGE � C2 1 YRS STEEL O CORROSION &r UNKNOWN <br /> O OTHER O UNKNOWN 0 OTHER O SPILL E::] OTHER <br /> wCHECKONEONLY <br /> 9 F-] UNDETERMINED O SOILONLY GROUNDWATER E::] DRINKNGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKONEONLY <br /> Z N <br /> ¢a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) Ej CLEANUP IN PROGRESS O SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> z w ❑ NO ACTK)N TAKEN Q POST CLEANUP MONITORING IN PROGRESS O NO FUNDS AVAILABLE TO PROCEED 0 EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> SCAP SITE(CD) a EXCAVATE&DISPOSE(ED) O REMOVE FREE PRODUCT(FP) O ENHANCED BIO DEGRADATION(In <br /> CONTAINMENTBARRIER(CB) O EXCAVATE&TREAT(ET) E] PUMP&TREAT GROUNDWATER(GT) O REPLACE SUPPLY IRS) <br /> 0 TREATMENTATHOOKUP(HU) O NO ACTION REQUIRED INA) O OTHER(OT) <br /> q �lv�se�r%s► Y�Yt 0�. fc a�/iZeaGGCY/ 7� r <br /> w <br /> HSCSS(AQI <br />