Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES❑ �O)j LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 YES No YES ❑ NO ,I HEREBY CERMYTHAT I-HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> REPORT DATEDIBUTION SHOWN ON THE W UCTION SHEET ON THE BACK PAGE OFTHIS FORM.: , <br /> CASE A DISTRIBUTION tf <br /> rv SIGNED iTJs2ft�- <br /> DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> m <br /> Clcc <br /> NA- 201(201 ) y6Q-3,yr <br /> Ow REPRESENTING ❑ OWNERlOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> O 0zLOCALAGENCY ❑ OTHER <br /> ADDRESS <br /> yes N• � veer <br /> rr>!-� S - <br /> ETRE crry lv STATE ZIP <br /> J NAME CONTACT PERSON PHONE <br /> m <br /> z, ❑ UNKNOWN <br /> a Qa ADDRESS <br /> w p <br /> cr 0/47-2- e�' a� / - �'-��'� ni CITY '� <br /> STATE �Sz� ,P <br /> FACILITY NAME(IF APPLICABLE) gcrf Icc f31.1ers OPERATOR PHONE <br /> s _ _ _ 9y3 -266ve <br /> < ADDRESS <br /> wt'7 "'• ch �' STRE CITY J911.V r, �v COUNTY 9520v ZIP <br /> w CROSS STREET <br /> (art-e�� <br /> z LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> rm <br /> w ) <br /> wV <br /> Lu REGIONAL BOARD PHONE <br /> CL a <br /> 2 ( ) <br /> w (ty NAME QUANTITY LOST GA <br /> n <br /> Z> Co.S {1�✓ UNKNOWN <br /> m (2) <br /> y Z <br /> ❑ UNKNOWN In <br /> z DATE DISCOVERED HOW DISCOVERED 0 INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONSuj <br /> Y'V, <br /> w Q j 2_M!II1 a gylmgyl ❑ TANK TEST [E� TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑REMOVE CONTENTS dCLOSE TANK&REMOVE ❑REPAIR PIPING <br /> M d D Y <br /> O HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> N �[ <br /> o U YES ❑ NO IF YES,DATEM 4 2_DI I d C?yl I <br /> r ❑REPLACE TANK E]OTHER <br /> -a SOURCE OF DISCHARGE CAUS S) <br /> Ca ❑ .TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> y ❑ PIPINGLEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> N a CHECK ONE ONLY <br /> L) ❑ UNDETERMINED 0 SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> H ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN 0 CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> CAM 89X fd10fTNd) F-1EXCAVATE&DISPOSE(ED) E] REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J <br /> o S2 ❑ CAP SITE(CD) ❑ EXCAVATE s TREAT(ET) ❑ PUMP E TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> wc ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REWIRED(NA) ❑ TREATMENT AT HOOKUP(Hln ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> AlJ �a�tc s a f S)rc A ave beeAj r�r�me p 6 Co �,� s C <br /> Lu <br /> k-ve ,G eeN ts7-r� �. tcr�k tier G. yras berN se.,,f a /rtfj�-,� Md�i%yi.�q <br /> he,,, 'w<l�><e� -�k{s - cru r� �jue ��� ecr�.�Nf?i'NeI�74�V .► J <br /> HW 05M W <br />