Laserfiche WebLink
0 'fTWj7 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> YES NO <br /> REPORT BEEN FILEDT ❑ YES ❑ NO IHERE YCERTIFYTHATI HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ <br /> DIS UTION OWN TEE INSUCTION SHEET ON 7H CK PAGE OETHIS FORM <br /> REPORTTTDDATE 9 CASES 7-� <br /> / <br /> 9 v- <br /> 0.1 Ml 34 O • / Y SIGNED .. DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNA <br /> Maj REPRESENTING ❑ OWNEIVOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY ME <br /> SLOCAL AGENCY ❑ OTHER <br /> A/D/b E/.SA)S <br /> / STATE L— � I <br /> ,M NAME CONTACTPERSON P'HJO�N2EEBe <br /> i� IL .}? ❑ UNKNOWN <br /> HgADDRESS //•/� //�� /y/ <br /> /OOO✓ STREET l I/e,/�OO� �1LIe CITv <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> S /✓ #55 l Z ( ) <br /> ADDRESS CITY �' <br /> 7i6� STREET :// j,M� <br /> =UuTy v' n'7lQ <br /> yCROSS STREET <br /> /T/Y <br /> Z LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> wa�,J ,Pum. (Zv9 � <br /> REGIONAL BOARD PHONE <br /> '� ua (1) /)r� ` NAME QUANTITY LOST(GALLONS) <br /> O Gl V V �n l /�,/,Q�� <br /> ZL�/V� KNOWN <br /> r <br /> mz m <br /> ❑ UNKNOWN <br /> DAVE DISCOVERED HOW-7of v /v ❑DISCOVERED <br /> µKRTEST ❑ TANK REMOµNTROL ❑ SUBSURFACE RRFACE MONITORING ❑ NUISANCE CONDITIONS <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> ii UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK 6 REMOVE ❑REPAIR PIPING <br /> w u 0 v r <br /> HAS DISCHARGE�STOPPED T ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE. ❑CHANGE PROCEDURE <br /> o ❑ VES NO IF YES,DATE MI MI .1 v v ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> �a F-] TANK LEAK �NKNOWN ❑ OVERFILL ❑ RUPTUREtFAILURE ❑ SPILL <br /> MO+Q ❑ PIPING LEAK ❑ OTHER ❑ CORROSION KNOWN ❑ OTHER <br /> m w6 CHECK ONE ONLY <br /> O ❑ UNDETERMINED ❑ SOIL ONLY dROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> RELIMINARY SITE ASSESSMENT <br /> RKPLAN <br /> POLLUTION CHARACERIZATIO <br /> �y F-1 LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY SUBMITTED a PWT CLEANUP MONITORING NN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J IffF eY.R TOROETAW <br /> a ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY IRS) <br /> ❑O <br /> W 0 <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> Soilce„vds oN/7X1P,1N6 uis 0,0 -50tE. fzrr.T'�c v-c - T <br /> 3 <br /> 0 <br /> U <br /> MSC�1&'9W <br />