UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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on UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY F7 YES NO YES NO REPORT BEEN FILED 7 1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE ❑ � DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM- REEPORT DATE I CASE 1 VM �MI 1 9 SIGNED DATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE REPRESS TING ❑ ❑ COMPANY OR AGENCY NAME w OWNER OPERATOR REGIONAL BOARD aLOCAL AGENCY ❑ OTHER Q ADDRESS p/1^\� / Qt{ '^�� V• Ef \v � Y /L/irUrSTATE l�CNt-- ZIP w NAME CONTACT PERSON PHONE Z \ ❑ UNKNOWN ( ) Q a a ADDRESS �5 /�Q I y Lu Er I Q•�� STREET �- CITY STATE ZIPJ FlACILlTY NAME(IF APPLICABLE) OPERATOR PHONE zO ` ( ) ADDRESS �ov�S04�(�� h O 2 Z w �J� CITY COUNTY 21P — CROSS STREET m O LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE zN w U w w REGIONAL BOARD PHONE O co NAME QUANTITY LOST(GALLONS) W 0 `` ^nom\ Z w '� �1' ' "CJ V� 9-- ❑ J UNKNOWN �- _ c (2) D ❑ UNKNOWN Q b r- DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ RFACE MONITORING ❑ NUISANCE CONDITIONS /`�-' Lu z C' w MI Mi \DI of Yl Y ❑ TANK TEST ❑ TANK REMOVAL OTHER SCi (� a DATE DISCHARGE BEGAN METHOD USED TO STO DISCHARGE(CHECK ALL THAT APPLY) (1_ m > UNKNOWN F—]REMOVE CONTENTS ❑CLOSE TANK 8 REMOVE REPAIR PIPING O M M D D Y Y 0O HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK 8 FILL IN PLACE ❑CHANGE PROCEDURE Q� U / C`n YES ❑ NO IF YES,DATE r, I� l © REPLACE TANK ❑ OTHER � vM M D D V V -a SOURCE OF DISCHARGE CAUSE(S) w j< DANK LEAK �NKNOWN ❑ OVERFILL ❑ RUPTURE]FAILURE ❑ SPILL oC/) O ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑'UNKNOWN ❑ OTHER w w CHECK ONE NLY V)0- U UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER [:] DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY z ❑ NO ACTION TAKEN ❑��PREL ELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION w ❑ LEAK BEING CONFIRMED IMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) J ISEE BAGN fOR UETAlS) o O ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP 8 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) LU�- w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) cn z z w 0 O U HSC 05("0))