Laserfiche WebLink
• ; �. �g u-5.3 <br /> UNDERGROUND STORAGE ,ANK UNA ZED RELEASE (LEAK)i CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> F7 YES NO YES NO <br /> REPORT BEEN FLED 7 .1 HEREBY CERTIFYTHAT I HAVE DISTRE EDTHIS INFORMATION ACCORDING TO THE <br /> r DLSTAIBUTION SHOWN ON THE N15TRUCTIDN SHEET ON THE BACK PAGE OF THIS FOR M <br /> REPORT DATE (( CASE S <br /> r `• o \ �' Sr.NFD DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE r cI <br /> co <br /> w REPRESENTING OWNER/OPE T ❑ REGIONAL BOARD COMPANY OR AGENCYrNAMCE -►WSJ" <br /> cc <br /> Lu1:1 LOCAL AGENCY OTHER-. a�� �( C <br /> LuR <br /> ADDRESS <br /> r� -C �4 STREET l�0 3 Cm Aa r�\ STATE CA , n(,�j3 7 <br /> w NAME CONTACTPERSON PHONEcc <br /> i `,j(� SCJ, ❑ UNKNOWN 1 �� h1` ) lD IG-S S <br /> Oa< ADDRESS <br /> VCA! STREET ccs LJ CT, STATE C p l 6 <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o )�raco mac;� 5a�� (�, �HT-7 <br /> UADDRESS <br /> w ►3 V So STREET W t s Cm �ll L1�.-r� COUNTY UN r1p <br /> - CROSS STREET 111 <br /> N �laS�\rt 62�n <br /> p LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> L, �� �o C v O Lu ( b <br /> wV <br /> PHONEZ <br /> --,:�oC. ,,r CO . �.,v,\ \'�, �av� l��so�, �v�ns (,1-0.1 ) qk0%..s,Ayb <br /> NAME QUANTITY LOST(GALLONS) <br /> LU O <br /> Z> c� UNKNOWN <br /> t <br /> co m <br /> N ❑ <br /> UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> :�MI 2 D C�`Y r ❑ TANK TEST ❑ TANK REMOVAL OTHER \ 1�(�J G <br /> am DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLYJ <br /> a <br /> Q �UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK a REMOVE ❑REPAIR PIPING <br /> Lu M D (� <br /> p HAS DISCHARGE BEEN STOPPED 7 y/ ❑REPAIR TANK ❑CLOSE TANK t\FILL IN PLACE CHANGE PROCEDURE tel! <br /> o YES [:] NO IF YES,DATE i�\ 6'ad r r E]REPLACE TANK OTHER �e 1K N 1 YV G <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> Lu <br /> a ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> O ❑ PIPING LFJJ( ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> Lu w CHECK ONE ONLY W <br /> u>a <br /> L) tf 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 /> Q <br /> N ❑ 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 /> c LD 0 ❑ CAP SITE(CD) EXCAVATE A TREAT(ET) PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> W <br /> w a ❑ CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(Hq ❑ VENT SOIL(VS) <br /> cr <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) <br /> H <br /> Cy, \r\ q�j sa` SarMR eq ri'(� uw W�(1 `�k� <br /> woarA ,. �`���s S /,s � - c� hyanoccv,��c(� io� <br /> m <br /> PN A nr �p v �'i. �Qrn � �l„�^NO-qp� z � rr�T(�jE N9 <br />