Laserfiche WebLink
1741, o, 'Ll <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCYHAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY. :�. .. <br />REPORT BEEN FILED? 1 HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TOTHE <br />❑ YES �J NO E::] YES ❑ NO <br />DISTRIBUTION SHOWN CN THE WSTR CTIO HEETON THE WKPAGE OF ISFOR <br />RE ORTDATE nyT�' CASE .1 -` �J <br />MI I d " v SIGNED - DATE <br />NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br />e 'G �3 <br />w REPRESENTING ❑ OWNERIOPERATOR ❑ REG NAL8OARD COMPANY OR AGENCY NAME <br />V <br />S � � <br />' <br />p LOCAL AGENCY ❑ OTHER /w Ind <br />ADDRESS <br />11//JY/ �2/(T)/(Y\�� <br />I 0 , 1✓ QTR V Ct �s/ SATE V ✓ <br />0 TICT PERSON \/ <br />{/-'}'�' vc k i I/Tg <br />./P�HO�N�E /y�C/'�.(•' A( <br />e `r 1 1 UNKNOWN <br />a a <br />ADDRESS L �/) p <br />Ori rove Cele ��UG� HATE //�/ <br />,r01 <br />FACILITY NAME (IF APPLICABL,E)` PERATOR /PHONE <br />o <br />0 <br />oo�!ted <br />ADDRESS 2 1 /\' �yt-/+ ypl [�/(�%J� �//%�/ i�v <br />L/• <br />/ ✓ �STREEf \ ✓ V V CRV J U 1 C UNry `�ZIP <br />- <br />CROSS STREET <br />N �`I <br />O <br />LOCALNCV AGENCY NAME CONTACT PERSON PHOjJE,� �� '�J <br />_� <br />Q <br />J� <br />w <br />REGIONAL BOARD PHONE <br />1�3 <br />6VZW c.e <br />(�) NAME QUANTITY LOST (GALLONS) <br />Zw <br />G" . T �J ❑ UNKNOWN <br />Nffi o <br />- <br />(2) <br />❑ UNKNOWN <br />DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />z <br />❑ TANK TEST ❑ TANK REMOVAL ❑ OTHER <br />w <br />M MI D D v <br />DATE DI$CMAR G METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />CLOSE TANK&REMOVE ❑REPAIR PIPING <br />t <br />( ❑ UNKNOWN ❑ REMOVE CONTENTS <br />IMID <br />Q <br />RBE <br />HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE <br />❑ YES ❑ NO IFYES. DATE ❑REPLACE TANK ❑OTHER <br />MI ml o ol yjv <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />w <br />¢j <br />❑ TANK LEAK UNKNOWN <br />❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br />00 <br />❑ PIPING LEAK ❑ OTHER <br />❑ CORROSION UNKNOWN ❑ OTHER <br />w <br />U <br />CHECK ONE ONLY SOIL ONLY GROUNDWATER DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />UNDETERMINED ❑ ❑ ❑ <br />HECK ONE ONLY <br />w� <br />❑ NO ACTION TAKEN F-1PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />¢r <br />❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br />O y <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br />CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />o <br />n� s <br />❑ CAP SITE (CO) ❑ EXCAVATE & TREAT (ET) ❑ PUMP &TREAT GROUNDWATER (GT) E::]REPLACE SUPPLY (RS) <br />0 <br />20 <br />❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />❑ VACUUM EXTRACT (VE) ❑ OTHER (OT) <br />ry <br />U L �e 102�witi'uJI <br />�elp ; �P� d �:�rLt �,,) (l <br />�,O� <br />ocA� <br />e -r Kw kie. .� i� r� C;, d�Gfe t �I^ <br />Q <br />r�.O, a� <br />Ru�l M <br />