Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES. FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 <br /> ❑ VES �O ❑VES I HEREBY CERTIFY THAT I AM A.DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> REPORTED S INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTIO 25150.7 OF <br /> REPO R/TD/ATE b CASES THE HEAL A DSAFTY D <br /> pm:� M D O Y Y SIGNED DA . <br /> NAME OF INDIVIDU CEILING REPOgT PHONE SIGNAT R <br /> > K•VOZ (� 001) y,(8 syzv <br /> PEPPER ING ❑ OWNEWOPERATOR ❑ REGIONALSOARD COMPANY OR AGENCY N/AAME <br /> i OCCAL AGENCY ❑ OTHEfl G 11� <br /> L <br /> LJ o <br /> NAME NTACT PECITY <br /> RSON PHONE 21P <br /> Ali I <br /> z auNKNowN <br /> S i ADDRESS <br /> FACILITY NAME(IF APP ICABLE) srATE P P <br /> OPERATOR PHONE <br /> z <br /> a ADDRESS ( ) <br /> STRE DVb <br /> _ <br /> Z CROSS STREET TYPEOFAREA E19-116 ❑WDUSTRIAL RURAL TYPEOFBUSINESgNTM <br /> MMERCLIL ❑ RETAIL FUEL STATION <br /> ter11. <br /> LOCAL AGENCY AGEING ❑RESIDENTIAL ❑OTHER E::] FARM �6THER <br /> PPRS <br /> Y NAME <br /> NTACTPERSON /� �� �f//J <br /> PHO <br /> J w REGIONAL BOARD <br /> PHONE <br /> l ) <br /> w p / n NAME QUANTITY LOST(GALLONS) <br /> 9 p (2) �UN(NOWIN <br /> w <br /> ❑ UNKNOWN <br /> W DATEDISCOVERED (� HOWDISCOVERED O INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITX7NS <br /> M _ M LD �D p Y y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISC HARGE(CHECK ALL THAT APPLY) / <br /> w Y UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK CJ yLTANK <br /> Q HASDISCHARG SEENSTOPPED7 ❑ REPAIRTANK ❑ REPAIRPWING ❑ CHANGE PROCEDURE <br /> o �❑ NO IFYES,DATE ❑ OTHER <br /> 'J <br /> M 0 D Y Y <br /> H SOURCE OF DISCHARGE TANKS OgNLVA VACITY MATERIAL <br /> CAUSE(S) <br /> ❑ TANKLEAK �UNKNOWN J �d GAL, ❑ FIBERGLASS <br /> ❑ OVERFILL ❑ RUPTUREFAILURE <br /> ❑ PIPING LEAK AGE Vflg ©STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> W, CHECKONEONLY <br /> Un <br /> � UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> ¢` ❑ S VESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> �H NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTQN(S)(SEE BACK FOR DETAILS) <br /> 4 DC AIR <br /> SITE(CD) ❑ EXCAVATE 8 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) E] ENHANCED BIO DEGRADATION(IT) <br /> O <br /> 2 ❑ CONTAINMENT BARRIER(CS) ❑ EXCAVATE B TREAT(ET) ❑ PUMPB TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> ❑ TREATMENTAT HOOKUP(HU) ❑ NO ACTION REQUIRED INA) OTHER(OT) <br /> w <br /> s <br /> HSCn(4W) <br />