Laserfiche WebLink
FILE C0pr-q-t_1,eU [r !f <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> ,FOR LOCAL-AGENCY USE ONLY <br /> REPORT BEEN FILED? <br /> ❑ YES NO ❑ YES ❑ NO 1HEREBYCER>IFYTHAT:i,HAVE DiSTRIBUTEDTHIS(FORMATIONACCORpINGTOTHE <br /> DISTRIBUTION SHOWN ON THE iNSTRUCT10N SHEET ON THE SACK PAGE OF THIS.FORAI <br /> REPORT DATE <br /> GASE t <br /> O SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> LOfLI D UN6i4,U <br /> ww REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> 2 9 LOCAL AGENCY ❑ OTHER SlWTOPrM.Xn)0-OVA E- L—,W rJ�w(�Xl'WL <br /> cc ADDRESS �-{ <br /> 3 0 1 STREET W fi� cm S T�CI`�I srA1E rP <br /> wNAME CONTACT PERSON <br /> � 11 VPHONE <br /> zco <br /> I: ll -o m UNKNOWN SI}1Mf ( ) <br /> co <br /> CL a ADDRESS (7 <br /> Q i�O STREET C4w fz m ` f/�1� <br /> - CITI' STATE 71P I <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE A <br /> e_k i=5 <br /> c~ai ADDRESS <br /> Lt <br /> Lu srREtT �.�Ll�O 1ZNl/4— crrY ESGf}�b� O <br /> y <br /> CROSS STREET <br /> M.�-vJ A--` t 1_.J 1 zv <br /> O LOCAL AGENCY AGENCY NAME GONTACT PERSON PHONE <br /> �vA t,t vtJ PH'S D DVN L4N (zol) $S903_3 <br /> Lu <br /> w REGIONAL BOARD PHONE <br /> CL` GGvTmA[_. <br /> wf I l NAME QUANTITY LOST(GALLONS) <br /> O <br /> Z> <br /> �� ❑ UNKNOWN <br /> m> <br /> �z <br /> ❑ UNKNOWN <br /> z DATE DISCOVERED <br /> I Q NOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING F-1NUISANCECONDNIONS <br /> uj <br /> w Q l w� a� Y Y ❑ T QST ❑ TANK REMOVAL OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w O M Y EJ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> UHAS DISCHARGE BEEN STOPPED 9 ❑REPAIR TANK ❑CLOSE TANK 6 FILL IN PLACE ❑CHANGE PROCEDURE <br /> O YES ❑ NO IF YES,DATE u' e� rI Y ❑REPLACE TANK OTHER (- Q r- <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> u UA <br /> a ❑ TANK LEAK F-1UNKNOWN ❑ OVERFILL � RUPTUREIFAILURE ❑ SPILL <br /> V PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> y a CHECK ONE ONLY <br /> u ❑ UNDETERMINED 5Q 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 /> 2 <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE E DISPOSE <br /> J <br /> MW RACK KR 00w� ❑ (ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> a o ❑ CAP SITE(CO) ❑ EXCAVATE&TREAT(ET) ❑ PUMPS TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Lu <br /> Lu a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) b } <br /> w <br /> �yge ,,L unv t���l y 51�w"�c{cvar,` <br /> ui <br /> 0 <br /> 0 <br /> U <br /> NSC 05 W" <br />