UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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u 30 UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT EMERGENCY „^ HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY F7 YES �J NO REPORT BEEN FILED T ❑YES �� I HEREBY CERTIFY THAT 1 AM A.DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE iLJ REPORTED THIS INFORMATION TO LOCAL)X U ANT TO SECTION 25180.7 OF REPORT DATE CASEi THE HEALTHA 66AFi CODE / - OM l Y 3Y ---- '.SIGNED E DATE NAME OFINDIVIDUAL FILING REPORT Q PHONE SIGNATURE / - � 0 REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONALBOARD COMPANY\OR AGENCY NAME p L2-0r,'& ❑ OTHER 4 V 04 V l�✓L l�• + N ^` v ADDRESS (J SS A/ 1 \ �! I � STREEVG•I V�Q �! / CITY �G BfATE � � 2 NAME CONTACT PERSON PHONE �///� w� 0. S LJ- ❑ UNKNOWN ,C(' Jew Tyr/I _7 —• zQ E n ADDRESS Q "?—IV' [{, y, CITY fG STATE - FACILITY NAME(IF APPLICABLE) OPERATOR PHONE ADDRESS �� sTBEEr T t em a-N Cry couttry S� C_ 95366 W CROSSSTREET `TYPE OF AREA ❑COMMERCIAL❑INDUSTRIAL❑RTU/RAL TYPE OF BUSINESS ❑ RETAILFUELS ATION TL O ❑RESIDENTIAL ❑j HER �l/4oa $ Y� ❑ FARM Ea6T—HER UJCALAGEACY AGENCY NAME CONT CT PERIN PHONE o w REGIONAL BOARD PHONE (1) NAME QUANTITY LOST(GALLONS) W 1 t .❑/UNKNOWN > (2) UNKNOWN i DATE DISCOVERED � 2 HOWDISCOVERED ❑ INVENTORYCONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCECONDITIONS W VM 6.1 ( .1 'Al (}v J v ❑ TANK TEST TANK REMOVAL ❑ OTHER DATE DISCHARGE BEGAN ., METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) M M D o v Y UJ NMMOWN EMOVE CONTENTS ❑ REPLACETANK CLOSETANK HAS DISCHARGE BEENODATE �✓M 1 STOPPEDJo v �r F-] OTHERTANK ❑ REPAIRPIPING ❑ CHANGE EDURE yLl SOURCE OF DISCHARGE TANKS gONLYICAPACITV MATERIAL CAUSES) E] TANK LEAK -KNOWN Zd�COO GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ PIPINGLEAK AGE 'WC' YRS STEEL ❑ CORROSION �ITKNOWN ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER ww CHECKONEONLY V� UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AF TED) CHECK ONE ONLY a< ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) Taj m ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED EVALUATING CLEANUP ALTERNATIVES CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) 0 z ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADA ION(IT) 00 f� ❑ CONTAINMENT 13ARRIER ICE) ❑ EXCAVATE&TREAT(ET) ❑ PUMPS TREAT GROUNDWATER(BIT) ❑ REPLACE SUPPLY IRS) ❑ TREATMENT AT HOOKUP(HU) ❑ il/ NO ACTION REGUIRED(NA) OTHER(OT) f44tn < -1 Wi'�� / Sr ' L i I ” �7//G ��I� 2}�T�/ 67T COtI �N1/�✓! o /�'v7.