Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> REPORT BEEN FILED 7 FOR.LGCAL AGENCY'fJSE pNEY <br /> Q YES NO =om Y ❑ NO 1 HEREBY CEHr)FYTHATE HAVE D!$TR18UTEDT){IS iNFOF(MAT)ON ACCORDING TO THE <br /> REPORT OATS <br /> CASEJ. DISTRI8UT1pN SHOWN aIf THE(�i$TRUCTIQN SHEAT ON.7}{E BACK.FAGE OF;THtS FaRAL <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> S REPRESEN a OWNEWOPERATOR ❑ REGIONAL BOARD E:��FMIC HEALTH SERVICES <br /> LOCAL AGENCY OTHER <br /> a ADDRESS BOX <br /> 1N JOI�IN SET <br /> sra£Er crrr 44 N,& nn <br /> J NAME[[ ` CONTAC7PERSON r ONE y <br /> z ✓C»fi L eyrie i,� / a C^fit G/e/I-C] UNKNOWN L�v�JI7 ���77 Gt h 1 ypS 7 <br /> COL aa ADDRESS <br /> c <br /> Lu <br /> Baa <br /> STREET CITY STATE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ZIP <br /> ¢ ADDRESS <br /> U ^ /�/��'`, `.fir <br /> w G�JC rL L� +�/ D� STREET s C.Fr L/�'J �Lat/���Y�Gc�C�i FY <br /> F. CITY COUNTY p <br /> y CROSS STREET <br /> S'/;,-,—a. <br /> LOCALAGENCY AGENCY NM=- CONTACTPERSON <br /> Z <br /> PHONE <br /> Hy ( <br /> W <br /> Lu REGIONAL BOARD _ PHONE <br /> CL a rr <br /> of fi) NAME QUANTITY LOST(GALLONS) <br /> W <br /> 2 Lu <br /> z o `Lo a4 ee41 11�c s ,.��. a UNKNOWN <br /> U), (� <br /> ZZ <br /> ca UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED a NTORY CONTROL SUBSURFACE MONITORING E::] NUISANCE CONDITIONS <br /> w `� Q r TAiti*(TEST _ TANK REMOVAL OTHER <br /> co <br /> Qc DATE DISCHARGE 13EGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> o Y Y UNKNOWN REMOVE CONTENTS CLOSE TANK&REMOVE REPAIR PIPING <br /> 0Lu <br /> 0 HAS DIS ARGE BEEN STOPPED 7 E::]REPAIR TANK CLOSE TANK&FILL 1N PLACE EDCHANGE PROCEDURE {� <br /> =� YES � NO IF YES.DATE �I r Y REPLACE TANK Q OTHER `� <br /> O v� <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> u Lu <br /> ¢ a TANK LEAK 0 UNKNOWN OVERFILL n RLJBTfJRE1FAiLURE SPILL <br /> y c7 PIPING LEAK Q OTHER CORROSION IL�"J/UNKNOWN E] OTHER <br /> w W CH=ONY <br /> CL <br /> RMINED 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 /> W LEAK BEING CONFIRMED PRELIM KkRY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN Q CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE S DISPOSE(ED) REMOVE FREE PRODUCT(FP) E::] ENHANCED 810 DEGRADATION(IT) <br /> J ME BOCK KA OEW-M <br /> 50¢Z CAP SITE(co) @=VATE d TREAT(ET) PUMP&TREAT GROUNDWATER(GT)E�] REPLACE SUPPLY{RS) <br /> CONTAINMENT BARRIER(CS) NO ACTION REQUIRED(NA) a TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> Q ❑ VACUUM EXTRACT(VE) C„iER(OT) <br /> / T�f Z"� +�oG�S$'6Cc� T1s G��7G�/r>/caFs 7!."p G2Gl �- <br /> us <br /> Gt S `C ✓«�`� �Y /���r! r <br /> v Yey �1e rl f <br /> c/ f71 <br /> HSC 05(8?m <br />