Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE ASE (LEAK)/CONTAMINATION SITE REPORT <br /> HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCY USE ONLY <br /> ❑ YES 0 REPORT BEEN FILED? <br /> REPORT DATE ❑YES ❑ NO I HEREBY CERTIFY IjHA7 t AM A DE$1Gt�ATEp GQYERV�NttJ EMPLOYEiANp" TH4Al7. AVE <br /> casE r REPORTER T#iIS INFORMATION TO!t?OA!OFF PURSUANT TO$ECT(QM :t) j HOF% <br /> THEHEAI lH ANO S :. Y COOS <br /> OD 511) Y <br /> NAME OF INDIVIDUAL FILING REPORT SICikEQ <br /> 1/(��1 s PHONE SIGNATURE SFE <br /> p REPRESENTING <br /> ❑ OWNEWOPERATOR <br /> ElREGIONAL BOARD COMPANY OR AGENC NAME <br /> cr <br /> a LOCAL AGENCY OTHER �^/, `�., j <br /> ¢ ADDRESS �- �G�9-L g <br /> P0, Z Ol <br /> J NAME CITY <br /> m r S (� �� CONTACT PERSON STATE <br /> w ,JG/C v A/ ZIP <br /> Z¢ <br /> gd ADDRESS El UNKNOWN UNKNOWry /' .�/�J -7 /C—__ <br /> LLI <br /> Er <br /> (� �y <br /> FACILITY NAME(IF APPLICABLE) STREET / <br /> f� OP ATOR j�jV �^'V STATE <br /> 107 cc, <br /> �� ,V /` � G�k. PHONE <br /> 7)P <br /> ADDRESS �.>.IqN <br /> � <br /> 7115 <br /> l SAO cm v��C. <br /> � CROSS STREET A{ / <br /> TYPE OF AREA COUNTY <br /> L a c,I'' C ❑COMMERCIAL ❑INDUSTRIAL❑RURAL TYPE OF BUSINESS <br /> ZIP <br /> ( L"t►+" Lewi5 � [::]RESIDENTIAL ❑OTHER ❑ RETAIL FUEL STATION <br /> LOCAL AGENCY ❑ FARM ❑ OTHER <br /> h AGENCY NAME CONTACT PERSON <br /> w ✓ /V PHONE <br /> W G1, <br /> w� REGIONAL BOARD ei Co L L A� � (ST <br /> d <br /> C v PHONE 6 J <br /> (� �t 66p'd G N go <br /> rn <br /> w p NAME <br /> J 9 QUANTITY LOST(GALLONS) <br /> (2) 'v — <br /> p UNKNOWN <br /> cn <br /> Z DATEDISCOVERED HOWDISCOVERED ❑ UNKNOWN <br /> L Q "7 INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> M M D vy ! y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> i <br /> jM M D D v y UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED) ❑ REPAIR TANK ❑ REPAIR PIPING '�CHANGE PROCEDURE <br /> p YESNO IFYES,DATE /1 OTHER <br /> ❑ ! M )-DU DIS Y y ❑ <br /> SOURCE OF(DISCHARGE <br /> p�Sy TA���NLY PACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK Inl UNKNOWN �L7t?UU(� GAL, ❑ FIBERGLASS E] OVERFILL ❑ RUPTURE/FAILURE <br /> jEl PIPING LEAK ��+ AGE YRSSTEEL ❑ CORROSION ❑ UNKNOWN <br /> ❑ OTHER NKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w w CHECK ONE ONLY <br /> U ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> r- CHECK ONE ONLY <br /> Z N <br /> Cc r <br /> a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> L)N ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 4 Z ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> oo <br /> w ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> cc ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REOUIRED(NA) ❑ OTHER(OT) <br /> r /I <br /> w � ��► <br /> RSC 0s(4187) <br />