Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICEOF EMERGENCE( ER ICS FOR LOCAL AGENCY USE ONLY -1 <br /> REPORTBEENTiILED 7' <br /> ❑ YES NO - - ❑ yEg W6 IHEREBY CER IFYTHATI HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE RUCTION.SHEET.ON THE BACK PAGE OF THIS.FORM. <br /> REPORT DATE p CASE <br /> u u 2 a- / r $13NED: DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> R_ y�vnJ ESL'. 1 2- <br /> w REPRESENTING lam``OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> S ❑ LOCALAGENCY ❑ OTHER <br /> ADDRESS <br /> P U . aax �f ODy 5Aw ,Qgfyav, CA 9HS63-OSOH <br /> STREET CRY STATE <br /> ZIP <br /> J NAME CONTACT PERSON /PHONE <br /> i¢ — E:] UNKNOWN <br /> m y ADDRESS <br /> �'0 drx SO(9Y sw x4meAl" C/ 9yse3-OPCJS1 <br /> 3TREEi CRV STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> N SeTercE S> 2033 (,gyp 7) <br /> < ADDRESS p� <br /> g 50 8 kl",- ClifKTER WRy STdc KTdnl S/tN JDcg41V/N/ 95.206 <br /> yCROSS STREET zlv <br /> LJ N�nLN <br /> i LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> 1=w <br /> w SJtJd Jolq�w,l yBut T En [fs A"N e)LX- <br /> REGIONAL BOARD PHONE <br /> 6, Cti Z96E7AA ( � IHSS-3133 <br /> w (�) NAME QUANTITY LOST(GALLONS) <br /> 0 <br /> aUNKNOWN <br /> N <br /> ❑ UNKNOWN <br /> W DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 0�3 S -1 <7 yl y ❑ TANK TEST ❑ TANK REMOVAL '® OTHER SuASYRr qeC JI/✓£ST164ZI /V <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M o y y UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK REMOVE ❑REPAIR PIPING <br /> 8 HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o ❑ YES 0 <br /> NO IFYES,DATE .1 j o y y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢j ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> ❑ PIPINGLEAK !❑ OTHER ❑ CORROSION '�. UNKNOWN ❑ OTHER <br /> iu a CHECK ONE ONLY �{ <br /> F-1UNDETERMINED ❑ SOIL ONLY Jg 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 /> My ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ 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 /> Pff APPROPRIATE <br /> otT A <br /> QZ <br /> wFl CAP SITE(CD) ❑ EXCAVATE 8.TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY IRS) <br /> F <br /> c< ❑ CONTAINMENT BARRIER(CB) ❑ NOACTION REWIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ <br /> VACUUM EXTRACT(VE) OTHER(OT) T/! 60:iNE S'OL/R['E ALVA cx7r�.IT <br /> �JJSCAQ[�C �E`FA�`:(J7EQ 8Y K�S�A✓J)L /hORD[aRgoNS AeTecr�p �N 50/L. NO <br /> KAJOrJN SauRLE; IVO 19c-1101V TAX&V /1T T#C /RE.SETl7' T/ME TO STOP, <br /> $ GaevA/nJ✓tTt9e /N dN1TORJN( IM�L�ML�JTE�. <br /> xsc os Iwm <br />