Laserfiche WebLink
} <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCYHAS STATE OFFICE OF EMERGENCY BEflYKS FOR LOCAL AGENCY USE ONLY <br /> ❑YES <br /> REPORTSEENFLED7 - <br /> NO ❑YES ❑ Np CHEAESY CERTIFY THAT I AM A DESIGNATED GQVEANMENC EMPLOYEE AND THAT i HAVE <br /> REPORTED THIS INFORMATION TO.LOCAL OFFICIA S PURSUANT TO SECTION 251SQ1 OF <br /> 0 RT DATE9 ^ 9 CASES THEHEAL: <br /> uml <br /> D ! v` •r SIGNED T <br /> it <br /> NAME OF INDIVIDUAL FILMR�ppRT /J PHONE SIGNATU <br /> Po LW-39 q 1 <br /> REPRESE NG <br /> c <br /> �w ❑ OWNEROPEMTOR F-1REGKINAL BOARD COMPANY OR AGENCY NAM <br /> p [ErLOMAGENCY ❑ OTHER L H D <br /> ADDRES0. '�✓n ^ Q O �lr�^ �O �T q _ yt <br /> ..` '(([[JJ P_7 srner_T S J /�, � C.. /7 `z�o / <br /> u� NAME CONTACT PERSON PHONE��1��'�����_ ///��� ' / - /T RATE ox-'Al Lily <br /> Na zt � Ty�j) S/j ❑ UNKNOWN /L// ` �3-aboo <br /> 70©D ,�•� �//�� S' ���rr1ti CFS 1 add <br /> FACILITY NAME(IF APPLICABLE) v <br /> � Q OPERATOR <br /> '4ose h s OS Q SATPEHDNE <br /> a <br /> �oY>9y3-acrso <br /> ���oo N Ca <br /> sTneer ceuwrr o <br /> $ CROSSSTREET TYPE OF ❑COMMERCIAL❑NDUSTRIAL❑RURAL TYPE OF BUSINESS Q RETAIL FUELST TON <br /> RESIDENTIAL [1]OTHER ❑ FARM �ER <br /> Q g LOCAL AGENCY AGER NAME OD <br /> CTPERSON PHONE <br /> p PS <br /> REGIONAL BOARD PHONE <br /> It <br /> C 8 , <br /> (1) NAMEU^^NOWN <br /> OUANTRY LOST(GALLON <br /> �� —1 ✓(�Q�� LJ <br /> (A <br /> ❑ UNKNOWN <br /> CI+ i DATE DISCOVERED (/n HOW OISCOVE D ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> �` w Ow �o �D Y `✓ Y ANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGANMETHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> u w o o r r UNKNOWN C:3 REMOVE <br /> CONTENTS ❑ REPLACETANK ❑ CLOSE TANK <br /> HASD ARGE BEEN STOPPED T (rX Xry ❑ REPAIRTANK ❑ REPAIRPIPNG ❑ CHANGEPROCEDURE <br /> p 7YES ❑ NO IFYES•DATE /u / u �P ' o U rj ?+ Y ❑ OTHER <br /> ETANKHARGE TANKSONNLY'CAPACINMATERIAL CAUSE(S) <br /> AIC ❑ UNKNOWN / VI(J(J( / GAL ❑ FIBERGLASS ❑ OVERFLL ❑ RR/UPTUREIFALURE <br /> LEA)( AGEE YRS STEEL ❑ CORROSION [9-'UNKNOWN <br /> ❑ UNKNOWN ❑ OTHER ❑ SPILL E_I OTHER <br /> gW ECK <br /> CHON NLY <br /> 59 ❑UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTEDI <br /> CHECK ONE Y <br /> IN <br /> SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP W PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> �v ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCEDBK)DEGRADATION(IT) <br /> m� ❑ CONTAINMENT BARRIER IDB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENTAT HOOKUP QM ❑ NO ACTION REQUIRED INA) ❑ OTHER(07) <br /> V oo0 <br /> (�ry /i I —88 T/Lrt aSsPcl Qs h�i 's,2t- �c7ev' 7� fcvc� �c <br /> �d `` <br /> NSG 6(�f <br /> Cefe�C�l• <br />