Laserfiche WebLink
NMI ftw ..i <br />w o1w1 <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY " � HAS STATE OFFICE OF EMERGENCY SERVICES <br />�/ REPORT BEEN FILED 7 <br />❑ YES LAS '�' ❑ VES Raj �� <br />u <br />FOR LOCAL AGENCY USE ONLY: <br />l HEREBY CE TIFV THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br />`RM)RTEP T IS INFOR ATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25100.7 OF <br />REPORTOATE CASES <br />0-16.1 <br />THEH SAFE <br />:% o Y v <br />SIGNED <br />DA E <br />PHS RE <br />NAME FINDIVIDUALF ING RE RT PHONE3// <br />7 <br />%-b <br />0 <br />0 <br />REPRES G ❑ OWNERAOPERATOR ❑ REGIONALBOARD <br />COMP�OyRAGENCY E <br />LOCAL AGENCY ❑ OTHER <br />vv <br />ADDRESS <br />NAME <br />l <br />(O/N/7/A�PF� � SLATE <br />PHONE <br />6 <br />❑ UNKNOWN <br />/` V U'-+�AI.vVi"_' '�_ <br />33 c1e <br />y <br />ADDRESS <br />"CRY- SPATE IP <br />FACLI NAME(IF APPLICABLE) <br />OPERATOR PHONE <br />sf <br />5 (tory) 70 133/ <br />` <br />ADDRESS <br />O STPE� <br />TYPEOFAREA❑COMMERCIAL NDUSTRIAL❑RURAL <br />TYPEOFSUSINESS ❑RETAI/LF(�E,L ST <br />❑ RESIDENTIAL ❑ OTHER <br />❑ FARM ❑ OTHER <br />�57 � Y NAME <br />CONTACTPERSON <br />Hp <br />PHONE <br />w <br />` <br />I ' <br />SI <br />ii <br />REGIONAL BOARD <br />PHONE <br />PHONE <br />(1) /�/ E <br />TQUANTITY <br />L.� <br />LOST AAL S) <br />UNKNOWN <br />C4 <br />(2) <br />❑ UNKNOWN <br />a <br />DATEDISCOVEREDRED <br />HOWDI'DAY CONTROL SUBSURFACEMONITRG <br />_1 NUISANCE CONDITONS <br />u <br />M u o D Y r <br />❑ TANK TEST TANK <br />REMOVAL ❑ OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THATAPPLY) <br />❑ <br />w <br />M u D o v Y �I '^'AWN <br />REMOVE CONTENTS ❑ REPLACE TANK OSE TANK <br />HIS DISCHARGE BEEN STOPPED 7 <br />❑ REPAIRTANK ❑ REPAIRPPNG ❑ CHANGEPROCEDURE <br />o <br />VES ❑ NO PYES,DATE M (131 4 DI FYI Y <br />❑ OTHER <br />H <br />SOURCE OF DISCHARGE <br />❑ TANK LEAK UNKNOWN <br />TANKS ONLY)CAPACITY <br />�G dbG 7 GAL. <br />MATERIAL <br />❑ FIBERGLASS <br />CAUSE(S) <br />❑ OVERFILL RUPTUREFAILURE <br />❑ PIPING LEAK <br />AGE YRS <br />TEFL <br />❑ L� CORROSION UNKNOWN <br />❑ OTHER <br />UNKNOWN <br />❑ OTHER <br />❑ SPILL ❑ OTHER <br />Lu W <br />CHECKONEONLY <br />❑ UNDETERMINED SOILONLY ❑ GROUNDWATER E::]DRINKING WATER - (CHECK ONLY P WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />F <br />z N <br />CHECK ON NLY <br />i <br />SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />K=j, <br />❑ NOAcroNTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS <br />❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATINDCLEANUPALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />ozz <br />❑ CAP SITE (CD) ❑ EXCAVATE& DISPOSE (ED) <br />❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCEDBIODEGRADATION(IT) <br />wKa <br />❑ CONTAINMENT BARRIER (CB) ❑ EXCAVATE b TREAT (ET) <br />❑ PUMP B TREAT GROUNDWATER (GT) E::]REPLACESUPPLY(RS) <br />¢ <br />❑ TREATMENT AT HOOKUP (HU) ❑ NO ACTION REOUIRED INA) <br />❑ OTHER (OT) <br />w <br />a <br />w o1w1 <br />