Laserfiche WebLink
UNDERGROU D STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HASSTATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORTBEENFILED7 I HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE.AND THAT I HAVE <br /> ❑ YES - NO [::]YES ❑ NO REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7'.OF <br /> REPORT DATECASE0 THE HEALTH SAFTY CODE, <br /> M M o v yr <br /> SIGHED y —� /%� ' DaTE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> (20) --?-0,64 <br /> REPRESE ❑ OWNERIOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> 10'LOCALAGENCY ❑ OTHER <br /> ADDRESS <br /> YY S /V, n 1gOa u�i e �y� c l ATE g S�zw <br /> ,M NAME CONTACTPERSON PHONE <br /> i C ❑ UNKNOWN 24-% FS7—�g <br /> S n ADDRESS <br /> l sG�s S mss " fl'vr C�i?.TE 4 s3�$ <br /> FACILITY NAME(IF APPLICABLE) RATOR PHONE <br /> OPE <br /> 1u.: s fes.. /are .i ee r ,-v S/ti, V-00 <br /> ADDRESSC` 7�/ qsu <br /> /S/O/� J• STREET Ji. �l L/fr /p i- _7t✓/7 �Q�4/s7 P <br /> 0 CROSS STREET <br /> a LOCALAGENCY AGENCYNAME CONTACTPERSON PHONE <br /> aS o/ O� (109) (165f-JI(A-le <br /> REGIONAL BOARD PHONE <br /> (,) NAME QUANTITY LOST(GALLONS) <br /> (� uF�? ❑ UNKNOWN <br /> �J <br /> (`a <br /> ) <br /> ❑ UNKNOWN <br /> DATE DISCO ED HOW DISCOVERED ❑ NTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> I M MI Ool 3DI ?yl y ❑ TAN(TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M DI DI Y Y2�"UNKQTOWN ❑ REMOVECONTENTS ❑ REPLACETANK ❑ CLOSETANK <br /> HAS DISCHARGE BEEN STOPPED 4 ❑ REPAIRTANK ❑ REPAIRPWING ❑ CHANGE PROCEDURE <br /> ❑ YES ❑ NO IFYES.DATE M M 01 DI v r ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RE,FAILURE ❑ SPILL <br /> ❑ PIPINGLEAK ❑ OTHER ❑ CORROSION lin UNKNOWN ❑ OTHER <br /> CHECKO NLY <br /> UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECXONEONLY <br /> ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATIONPLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> :HECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) IZ <br /> 1✓+EE avxwxoEru� - <br /> ❑ CAPSITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ TA)MP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> ❑ CONTAINMENT BARRIER(CEI) ❑ NO ACTION REQUIRED INA) ❑ TREATMENTAT HOOKUP(HU) ❑ VENTSOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> ��,Q ItcG�iLr.Y aba-G7 eX�• MT Co ie�4�'rr r�1 a�iv+7 p.-S- i-P Si G!!K /-y <br /> 10CAP <br />