Laserfiche WebLink
e�� <br /> N%w <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FLED? I HEREBY CERTIFY THAT I 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 /> REPORTDATE CASE* THE H AND SAFTY CODE <br /> O4 1/( M D rIQY -!TGNET' T TSS._E <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> 7,q?) 1 (��Lr <br /> m <br /> o REPRE NTING ElOWNERlOPERATOR ❑ REGIONAL BOCOMPANY OR AGENCY NAME <br /> ARD //77 J <br /> o LOCAL AGENCY ❑ OTHER 37/J J�f �v�, L c", <br /> a <br /> cc <br /> ADDRESS <br /> '(7r lggt`1 u N STREET CITY `' STATE 5�.rz0 i, ZIP <br /> I <br /> w NAME CONTACT PERSON PHONE <br /> z ��. <br /> El UNKNOWN ar�IF` � N (�,1) y -r .j,` <br /> g a ADDRESS <br /> 1 / - <br /> 1 -}/J'} R <br /> STREET 1^-' -�'v � CRY STATE /Z <br /> O6 ZIP <br /> FACILITY NAME(IF APPLICABLE) V OPERATOR PHONE <br /> �• r�S '/�, rNly_ Y rY' (tai) <br /> ua ADDRESS <br /> w ! J STREET , , /�, CITY -'V COUNTY Z06ZIP <br /> y ROSS STREET TYPE OF AREA COMMERCIAL F7 INDUSTRIAL❑RUR TYPE OF BUSINESS RETAIL FUEL STATION <br /> aw ry,, ❑RESIDENTIAL ❑OTHER ❑ FARM THER <br /> LOCALAGENCY If AGENCYNAME CONTACT PERSON PHONE <br /> Z� ,.� n �(/n. 0u.v,• ��rc r��� �'d/CF''�: mss' .�- <br /> W w REGIONAL BO RD PHONE <br /> CL¢ ( ) <br /> (�) _ NAME QUANTITY LOST(GALLONS) <br /> N <br /> w C'�TC157)I/�P ❑ <br /> O UNKNOWN <br /> Q J <br /> �O (2) <br /> V7Z) ❑ <br /> UNKNOWN <br /> z <br /> f DATE DISCOVERED HOW DISCOVERED F7 INVENTORY CONTROL ❑ SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> W M I M 'D D IT Y Y ❑ TANK TEST Fj2/TANK REMOVAL ❑ OTHER <br /> r <br /> GATE D14CHARGt BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M 0 D Y y UNKNOWN <br /> E:] REMOVE CONTENTS a REPLACE TANK CLOSE TANK <br /> > HAS DI HARGE BEEN STOPPED? ❑ REPAIR TANK a REPAIR PIPING a CHANGE PROCEDURE <br /> p I YES E::] NO IFYES•DATE M MI D D r v ❑ OTHER <br /> w SOURCE OF DISCHARGE TANKS ONLYr-APACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK DISCHARGE <br /> �s 000OVd GAL. E:] FIBERGLASS a OVERFILL a RUPTURE FAILURE <br /> 0 PIPING LEAK AGE CC 6YRS IVSTEEL El CORROSION VIUNKNOWN <br /> 2 ! [:] OTHER ❑ UNKNOWN ❑ OTHER a SPILL O OTHER <br /> w w I CHECK ONE ONLY <br /> ❑ UNDETERMINED SOLI ONLY ❑ GROUNDWATER ❑ ORINKNJG WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> yCHECKONEONLYE] SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY)❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> oI ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REOUIRED(NA) ❑ OTHER(OT) <br /> ja N k Rtmom I --,f u FES / 1°r1/s -so I/ c�, a�, /.ems . furf.��r si �rss«�{v►�,=.�-� <br /> ZZ w:i> 6E, <br /> 0 "7 a��aiar r�U/mar, ,�v�ciPs <br /> HSCOS(AA7) <br /> ( <br />