Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> ::FOR:LOCAL>AGENCY;USE-0 <br /> REPORTBEEN FILED <br /> 7 ::::.................:.. <br /> ❑ YES No : .;:.:»:;.;;>;;.::;:;:;.:;;:;::>:;;•;:.> ;;::.:.;:, :::>::;:::;>.; <br /> ❑ YES (� No EHTIFY?HAT.i;HAKE:DIgT %TEDTHIS:INFORMA7JON;JICCOIiDING,TOTHE ....:;;:;:: <br /> REPORT DATE QISTRIBUTICN$HOWyglTH) JN.M CTbkN:E�TON7HESACKPAGF OF THIS FORM <br /> CASE R >- <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> } NtiUIV h V7jN jup. (2aj) ub 0-a a <br /> w REPRESENTING ❑ <br /> r OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> S LOCAL AGENCY ❑ OTHER cJ �' v f no Al ems►4L IkA <br /> ¢ ADDRESS <br /> (rU <br /> C(TY STATE <br /> J NAME ! CONTACTPERSON ZiP <br /> /� 1i r l J �j�� PHONE A? '(`U <br /> z� ( 4�1. C/ ❑ UNKNOWN V l+ II '.+c�1 (2®7) /J 7-7J / <br /> a aQ ADDRESS <br /> cnw <br /> cc <br /> STREEr <br /> FACILITY NAME(IF APPLICABLE) cm STATE ZIPOPERATOR <br /> o � e� <br /> ��eM �- Nc E- . u N <br /> < ADDRESS <br /> Fw- STRE C ' \ Sovt, <br /> � CROSS STREET COUNTY ZIP <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> ujol5sc 6 v h U N r VMAI (.16*-3 <br /> w w REGIONAL BOARD <br /> C e'l It VL U��( Rc�verh) CerL.A44 <br /> NAME <br /> W y QUANTITY LOST(GALLONS) <br /> l <br /> zW C r <br /> > /R►� rr <br /> p �) O V UNKNOWN <br /> 23 <br /> D- <br /> y <br /> ❑ UNKNOWN <br /> I.- <br /> DATE DISCOVERED HOW DISCOVERED E] INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 2 MI 2,1oI YI Y ❑ TANK TEST W TANK REMOVAL ❑ OTHER <br /> ® DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> w M M o o Y r Na UNKNOWN ❑REMOVE CONTENTS CLOSE TANK d REMOVE ❑REPAIR PIPING <br /> SHAS DISCHARGE BEEN STOPPED 1 ❑REPAIR TANK ❑CLOSE TANK s FILL IN PLACE ❑CHANGE PROCEDURE <br /> LA <br /> C3 YES ❑ NO IF YES,DATE D M I o S /h Y Y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE <br /> CAUSE(S) <br /> jw <br /> j ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> a <br /> y U ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> Ww CHECK ONE ONLY <br /> CL <br /> U UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w <br /> Q <br /> cry LEAK BEING CONFIRMED ❑ PRELIMINARYSITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION <br /> {IT) <br /> J <br /> o O ❑ (SF£fl4CK FOR OEfAl3)CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP 6 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w~ <br /> I-Q ❑ GONT-ALNMENT BA-R-RIFR(CB) Nib-ACYMN-RE U NA <br /> D 1 ) ❑ TReATMENr-AT 0KUP(Fl[1) ❑ -VENT-SOIL-(VS)- <br /> c—VACUUM EXTRACT(VE) OTHER(OT) vj S <br /> deo Q tui <br /> HSC 05(090) <br />