Laserfiche WebLink
ql Io3 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> YES NO REPORT BEEN FILED? ❑YES � NO REPORTED TH Y CERTIFY.5 NFORMATION�TO DESIGNATED <br /> LOCAL OFFICIALS PURSUANT GOVERNMENT <br /> URSUANT TO SECTION 25180.7 OF <br /> REPORT DATE CASES THE HEALTH AND SAFTY CODE <br /> M CYJ <br /> .1 S D �1 1 Y SIGNED.�"'� f Com'DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> /e�4nr a',' -�I" I� tot)y6�--3'(SL/ <br /> d REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> O LOCAL AGENCY ❑ OTHER <br /> w <br /> cc ADDRESS yf�j� <br /> 4J© W STREET `/7� f/ �(If J04.9""-1 U7y G - ` SPATE "-� !�IP�/ <br /> NAME cbNTACTPERSON PHONE <br /> l r m <br /> cn qw l �j' � f�✓l UNKNOWN �V G 4Z�J� `�''r7s <br /> R a ADDRESS <br /> U) <br /> tr w 2-6 so 1 <br /> STREET C✓L CRY ��^-�T STATE ZIP <br /> FACILITY NAME IIF APPLICABLE) OPERATOR PHONE <br /> o+-'. LoA Pav1 e, 1 Cy07Z$ <br /> C ADDRESS <br /> J " <'o I STREET V1 &I(-`& COUNTY LP <br /> NCROSS STREET TYPE OF AREA COMMERCIAL INDUSTRIAL AL PE OF BUSINESS ❑ RETAIL FUEL STATION <br /> RESIDENTIAL ❑OTHER �RM E] OTHER <br /> LOCAL AGENCY AGENCY NAME OONTACT PERSON PHONE <br /> Lu <br /> w REGIONAL BOARD PHONE <br /> CL GR'I-� 1CC� er 4�IG ) ��- 5726 <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> ! C rt L L� L l��R ►C� UNKNOWN <br /> J <br /> ~ () <br /> UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lu <br /> S.1Q 1 -1 v 0 TANK TEST ❑ TANK REMOVAL �THER '41 ofs ✓i <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> �NKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> M M M D D Y Y <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING CHANGE PROCEDURE <br /> p ❑ YES [� IFYES,DATE M M D D v Y ❑ OTHER _ <br /> w SOURCE OF DISCHARGE TANKS ONLYICAPACITY MATERIAL CAUSE(S) <br /> TANK LEAK UNKNOWN ���r^ 1-51 GAL. Q FIBERGLASS 0 OVERFILL E�] RUPTUREIFAILURE <br /> PIPING LEAK AGE - YRS '❑STEEL ❑ CORROSION �NOWN <br /> 9 ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w w CHECK ONE ONLY <br /> 0 OL <br /> ❑ UNDETERMINED ❑ SOILONLY GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHEO LY <br /> Z f7J <br /> ¢ CK SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) [7] CLEANUP IN PROGRESS E] SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> ¢r <br /> y ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 0 z ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT 13ARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> TREATMENT AT HOOKUP(HU) NO ACTION REQUIRED(NA) O OTHER(OT) <br /> S C SS MC' ,r's 7b Ple Xerstln i +� '✓�C <br /> z r ,�a'✓1 e"I lkm 419 hla4 , 1�--�i✓L r ra�•sc i� �`� A rS�vi }` rl•ry <br /> r <br /> w mora`011 py <br /> HSC 0514W) <br />