Laserfiche WebLink
L.- <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> El YES ,yu-�/� REPORT BEEN FILED? YES r�/No I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> LJ REPORTED THIS.INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORTDATE CASES TH-H ALTH AN SAFTV ODE,`^` <br /> �J � / l <br /> u 7•M �i6 Yl 5 v BGN DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNA. RE <br /> 0 REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONALSOARD COMPANY OR AGENCY <br /> /NAME <br /> pq¢ �we'LOCALAGENCY ❑ OTHER ST <br /> ¢ ADDRESS <br /> vi3 F-00 <br /> NAME / CONTACTPERSON PHONE <br /> Ka ,k �,un vv - '>JkSUNKNOWN MJA./ ( nl � I -,;-( &I <br /> ADDRESS /\►' // (p/y, /�/`�� <br /> AAA¢M1 •O• 3 J 811ffET s ac,4� �y g�ATE WJ �J�� <br /> FACILITY NAME(IF PPLICABLE) OPERATOR PHONE <br /> G.<.u�- u s�. S ) q 3 1Sb61 <br /> ADDRESS 35.�z Ct � SNs 7,-ia <br /> yCROSS STREET N/ ❑ ❑ ®TYPE OF AREA COMMERCULL❑INDUSTRIAL❑RURAL TYPE OF BUSINESS E::] RETAIL FUEL STATION <br /> RESIDENTIAL OTHER ❑ FARM OTHER <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> �W .SZ•f�•c�. �,1�. � Cdr �Z�St Y68-3yzo <br /> REGIONAL BOARD PHONE <br /> (1) NAME QUANTRY LOST(GALLONS) <br /> w <br /> O� UNKNOWN <br /> 6J <br /> j (2) <br /> �— ❑ UNKNOWN <br /> DATEDISCOVEREDs� HOW DI RED E:] INVENTORY CONTROL ❑ SUBSURFACE MONITORING E:] NUISANCECONDITIONS <br /> u 3 u � Zo O Y r TANKTEST ❑ TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN ('� MKET�HO9 US ED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> u u o o v Y 2 UNKNGWN E A VE CONTENTS ❑ REPLACETANK ❑ CLOSE TANK <br /> HAS DISCH BEENSTOPPED? ❑ REPAIRTANK ❑ REPAIRPPNIG ❑ CHANGE PROCEDURE <br /> o YES ❑ NO IFYES,DATE M ml <br /> DI o YJ Y ❑ OTHER <br /> i SOURCE OF DISCHARGE TANKS PNLYICAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK dUNKNOWN DDU GAL. ❑ FIBERGLASS ❑ OVERFLLL ❑ TUREiFALLURE <br /> F-1L PIPINGLEAK AGE t4"lYRS STEEL E] CORROSION NUw <br /> ❑ OTHER �NKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w� CHECKONEON <br /> NDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ON LV <br /> SITE 6NESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> V� ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNIS AVAILABLE TO PROCEED E] EVALUATING CLEANUPALTERNATIVES <br /> CHECK APPROPRIATE ACTK)N(S)(SEE BACK FOR DETAILS) <br /> 3 ❑ CAP SITE(CD) ❑ EXCAVATE A DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BID DEGRADATION(11) <br /> wK� F-] CONTAINMENTBARRIEfl(CB) E:] EXCAVATE 6TREAT(ET) ❑ PUMPA TREAT GROUNDWATER(GT) E] REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REWIRED INN ❑ OTHER(OT) <br /> R9Go51AQ/1 <br />