Laserfiche WebLink
�I- U F) <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ VES NO REPORT BEEN FILED? ❑ YES ❑ NO I HEREBY CERTIFY THAT.I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> REPORTDATE CASE t DI TR IS ION SHOWN ON THE INS'I-RU Tb SHEET ON THE BACK PAGE OF THIS FORM <br /> ^ <br /> uM M <br /> r 'SIGNED �'. <br /> NAME OF INDIVIDUAL FILING EPORT TE '. <br /> ll PHONE SIG RE <br /> m T <br /> w REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> SLOCALAGENCY ❑ OTHER <br /> WE ADDRESS —r D <br /> STREE <br /> J NAMELTfr STATE II I <br /> m <br /> CONTACT PERSON PHONE I <br /> z EJ / <br /> ¢ L UNKNOWN 1 1 <br /> yu ADDRESS `LA1 I — <br /> ¢ STREET =PERATOR CITY <br /> FACILITY NAME(IF APPLICABLE) STATE <br /> PHONE v <br /> o ff �f <br /> ADDRESS <br /> O <br /> J <br /> STREET <br /> h CROSS STREET °ter couNTr n <br /> O LOCAL AGENCY •AGENCY NAME <br /> z y C CONTACTPERSON PHONE <br /> - <br /> w REGIONAL BOARD <br /> f a <br /> (PHONE ` <br /> W (�) NAME 1 l <br /> i ST w QUANTITY LO (GALLONS) <br /> F J � <br /> m i (2) �ONK OWN <br /> �- <br /> m <br /> E. DATE DISCOVERED ❑ UNK OWN <br /> w HOW DISCOVERED ❑ IN TORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDI IONS <br /> M o r <br /> r ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> Q DATE DISCHARGE BEGAN <br /> METHOD USED TO STOP DISCHARGE(C ALL THAT APPLY) <br /> w M o D r UNKNOWN ❑REMOVE CONTENTS LOSE TANK&REMOVE ❑REPAIR PIPING <br /> HAS DISCH E BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLgCE ❑CHANGE PROC DURE <br /> o YES ❑ NO IFYES,DATE B r y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSES) <br /> �a ❑ TANK LEAK [:9-'UNKNOWN ❑ OVERFILL ❑ RUP AILURE ❑ SPILL <br /> yO ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN <br /> ❑ OTHER <br /> ywa CHECKONE ONLY <br /> O ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wZ ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> jN ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY <br /> O ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> J ISFEflvx F]R oeTusl ❑ E%CAVATE&DSPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATI N I <br /> op ❑ CAPSITE(CD) ❑ EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER (T) <br /> w a ❑ ( T)❑ REPLACE SUPPLY(RS) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> �h 4.iZ -�E C3lSSEM�t.1 �oacS %`z o <br /> -�21MiNE -tkE ��c F Ei.1� c)-p COt�1 �0.Mit3��ION <br /> NSC 0(&Vq <br />