Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES 'FON.LOCAL'AGENCY USE ONLY. <br /> REPORT BEEN FILED 7 1HER BYCERTIFYTHATI HAVE DISTRIBUTEDTHIS INFORMATION ACCORDING TOTHE <br /> ❑ YES �NO ❑ YES ❑ NO <br /> DIS IBUTICN SH N THE i STRUCTK)N SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT Sul <br /> CASE �•� <br /> ami SM �J v SIGNED DATE <br /> NA OF INDIVIDUAL ILIN EPOR PHONE GNAT E r <br /> )5I °5 c!- <br /> w REPRESSOCANG ❑ NER/OPERATOR ❑ REGIONALBOARD COMPANYOR AGENCY NAME <br /> n LLAGENCY ❑ OTHER <br /> ¢ AD ES //,/[�jf� <br /> 0' (J 4 V D STREET C /• STATE(/'/ <br /> J NAM CONTTAACTPPERRSON /yL PHONE <br /> ZQ ❑ UNKNOWN d;4-6x <br /> it n ADDRESS <br /> w <br /> ¢ c./V SiREEf CIT STATE fJL <br /> FACILITY N (IF APPLICABLE) OPERATORPHONE <br /> Z c ) <br /> o <br /> ADDRESS <br /> /� <br /> g 7 S REST !/v. (/ Tti/� N•/' cm �/(J�-7l/ V/✓ cpV �/ Z11 <br /> mCROSS STREET <br /> ,Li NLot A/ <br /> i LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> �w <br /> wU � <br /> y�jw REGIONAL BOARD PHONE 1 <br /> w (7) NAME QUANTITY <br /> `LOST(GALLONS) <br /> Z w GOT �� ,,J ❑ UNKNOWN <br /> i RI 6 V <br /> ren ❑ UNKNOWN <br /> i DATE DISCPVERED Q r] HOW DISCOVERED ❑ INVENTORY CONTROL BSURFACE M NITORING NUI C CONDITIONS <br /> M '� a n gY ZT ❑ TANK TEST ❑ TANK REMOVAL �OTTHER <br /> m DATE DISCHARGE BEGAN p METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) Z <br /> ! yyj ❑ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE REPAIR IPING <br /> o HAS DESISC RG❑BEEN <br /> NOSTIOF Y[EFS DATE ZY.1 yj _j REPAIR TANK REPLACE TANK ❑OTM CLOSETANK8 FILL IN PLACE ❑CHANGE PPO CDU <br /> H tS�iGT <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢j ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILUREL <br /> ww PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN �- <br /> w w CHECKONEONLY <br /> 0 ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wZ ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> x j5 F-1 LEAK BEING <br /> J w ❑ REMEDIATION CONFIRMED CASE <br /> MED O PRELIMINARYCLOSEDLEMONITORING IN PROGRESS <br /> (EANUP COMP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> U <br /> CHECK APPROPRIATE ACTION(S) EeEXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ENHANCED BIODEGRADATION(IT) <br /> IeFEeWI.Rn okTUPI <br /> F3 0a 0 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REOUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> 341 A <br /> HSG0. <br />