Laserfiche WebLink
O 1 - u,0 3 <br /> UNDERGROUND STORAGE UNAUTHORIZED RELEASE (LEAK)/ +„,NTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> YES F7 NO YES ❑ NO <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OFTHIS FORM: <br /> REPORT DATE CASE a <br /> r �) -� SGNEB DATE <br /> NAMEr INDIVIDUAL FILING REPORT PHONE SIGNATURE 2 <br /> } <br /> m <br /> REPRESENTING ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> w OWNER/OPERATOR <br /> _ ❑ LOCAL AGENCY ❑ OTHER <br /> gADDRESS <br /> crry ZIP <br /> w NAME CONTACT P5RSON /�/�/r (PHO7NE <br /> cnc E] UNKNOWN <br /> z¢ <br /> O <br /> a'.I AOORESS77 <br /> � STREET CRY STATE P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o 6V <br /> _ <br /> a ADDRESS <br /> /c-/1-Y, <br /> CTTY pp <br /> w <br /> CROSS STREET <br /> O <br /> LCr AGENCY AGENCY NAME CONTACT PERS PHONE <br /> 6A <br /> L21 w REGIONAL.BOARD PHONE <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> 0 <br /> '/r /�t � ����❑ UNKNOWN <br /> 4 � <br /> °> m <br /> 0 Q <br /> z a <br /> � UNKNOWN <br /> DATE <br /> DISCOVERED NOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDmONS <br /> = L <br /> w �/w I u o rI r ❑ TANK TEST ❑ TANK REMOVAL ® OTHER _'sp/ >r <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Q M 1 p ) / ❑ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑ REPAIR PIPING <br /> O HAS DISCHARGE BEEN STOPPED/r7 1 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o YES ❑ NO IF YES,DATE MI / C p �d �I /y ❑REPLACE TANK N OTHERJ�l <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> L w <br /> n TANK LEAK n UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE SPILL <br /> w o ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> v ❑ UNDETERMINED/ ❑ SOIL ONLY ❑ 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 /> w <br /> ¢ ❑ LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> L) ❑ REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> (SEF a FOR WfA&t <br /> z ❑ EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> o O CAP SITE(CD) ❑ <br /> oF7CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> w ¢ <br /> ¢ ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> A� 1-L-R � F hL,u/ .titt- <br /> Z G�F Fitt (C(li�Li�LI�,. ���E'�v�l`' 51H PFr // r-aol- <br /> 7 6M//O s a� ,�•1As���i'/7 L,= �v�r //l/Z) �,�?7, ��./�ji L „ f-/,,E'er pal��, <br /> C"au?)Z/ oft' / �L77f S, �L�J CLZ'l��i ��f/h�'!� iZ` �» ?rn Hsc05I&W <br />