Laserfiche WebLink
N%0-01 y- <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS REPORT TEENOFFICE OF EMERGE SERVICES FOR LOCAL AGENCY USE ONLY <br /> ,_,.u/ REPORT BEEN FLED? HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT HAVE <br /> YES NO YES PID REPORTED THIS INFORMATION.TO LOCAL OFFICIALS PURSUANT TO SECTION 25160.7 OF <br /> REPORT DATE =CASE• THE HEALTH A!ZyN SAFTY CODE _ <br /> OM /Ml / WW DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> n REPRESE ING O OWNEWOPERATOR Q REGIONALSOARD COMPANY OR AGENCY NAME <br /> ¢O AL AGENCY O OTHER <br /> w <br /> ¢ ADDRESS <br /> Z!�!� Jal L%oee ,r-" o5• S�vc.E�oi, <br /> STEiEET CRY $FATE ZIP <br /> NAME CONTACT PERSON PHONE <br /> h� avn on D UNKNOWN avn Sa/mon ( ) <br /> y ADDRESS / <br /> 7 <br /> /76 ueS/L <br /> m 'T <br /> CITY WATE 2IP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> /n'/ /n rw�t nI ( ) Sa3 556 <br /> I' ADDRESS -THSOpQ QUM cO . <br /> /9TREE( <br /> Cm /// n C!I couKn 9.s.�-�6AE <br /> 55 CROSSSTREET TYPE OF AREA COMMERCIAL Q INDUSTRIAL O RURAL TYPE OF BUSINESS O gETAIL FUELSTATION <br /> V,Ik/n; I <br /> O RESIDENTIAL Q OTHER Q FARM ©OTHER <br /> LOCA AGENCY AGENCY NAME CONTACTPERSON PHONE <br /> wwoToa ' / �r ui e d a'-o/ O z— Yby 3 <br /> w REGK)NAL BOARD PHONE <br /> 3 ( ) <br /> ()) NAME OUANTITY LOST(GALLONS) <br /> nx �N(NOWN <br /> E!J' <br /> y� UNKNGWN <br /> Beer e/ <br /> i DATEDISCOVERED HOWDISCOVERED O ItJVENTORY CONTROL O SUBSURFACE MONITORING a NUISANCEOONDITIONS <br /> I M M D 'r.1 7,1 <br /> Y O Y E::] TANK TEST TANK REMOVAL E] OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> RE2/UNKNOWN REMOVECONTENTS Q REPLACETANK O CLOSE TANK <br /> M M D D Y Y <br /> HAS DISCHARGE BEEN STOPPED? REPAIR TANK REPAIRPIPING O CHANGE PROCEDURE <br /> c F-] YES O NO IFYES.DATE MI Ml D D YJ Y OTHER <br /> u� SOURCE OF DISCHARGE TANKS ONUWWACITY MATERIAL CAUSE(S) <br /> TANKLEAK UNKNOWN GAL. = FIB RGLASS = OVERFILL O RUPTUREIFACURE <br /> O PIPING LEAK AGE VflS STEEL 1:1 CORROSION E_4�NKNOWN <br /> O OTHER UNKNOWN O OTHER O SPILL = OTHER <br /> w CHECKONEONLY <br /> O UNDETERMINED a SOILONLY O GROUNDWATER ED DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECKONEONLY <br /> ct O SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) 0 CLEANUP IN PROGRESS O SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> Uy NOACTIONTAKEN 0 POST CLEANUP MONITORING IN PROGRESS O NO FUNDS AVAILABLE TO PROCEED = EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> O CAP SITE(CD) EXCAVATE&DISPOSE(ED) E:l REMOVE FREE PRODUCT(FP) O ENHANCED BIODEGRADATION(IT) <br /> O CONTAINMENT BARRIER(CS) O EXCAVATE TREAT(ET) O PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY IRS) Jz <br /> O TREATMENT AT HOOKUP CHU) Q NOACTIONREOUIRED(NN Q OTHER(OT) <br /> Fur�/�er s i/P a ss�ss/•n.¢...� w�!/ sr i.v'es s ate. 4a//y p/e/GY <br /> z <br /> � Goin'�+%•^�n4u3 /'e�'_ t!//WC/ V fXt a�/-O�HIc+H `ry H/w h'✓ <br /> ana/ o� �ion I/ <br /> NK:as(AM <br />