Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES EOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? <br /> Q YES NO 0 YES NO !HEREBK CERTIFY THAT I AM A DE$1GNJlTEO GQUERNMENT EMPLpYEE AND THA..E HAVE;: <br /> REPAR.. THIS fNF.ORMAT)�t TO LQC.AL QFF(CIACS PURSUANT Tp SEC7(pN 25x80 OF <br /> REPORT DATE CASE* THE TH ANO$ CQD <br /> M M I D Y Y rNE E':i <br /> NAME O NDIVIDUAL FILING REPORT PHONE SIGN T <br /> REPRESENT OWNER/OPERATOR Q REGIONAL BOARD COMPANY OR AGENCY NAME <br /> a0 L—✓J L/OCAL AGENCY ] OTHER <br /> w ADS S qlLr N. 5,9-,-,cf j6,;Z),w v T / 5C7Z)C1K -0 <br /> 9,5203 <br /> STREET <br /> STATE ZIP <br /> J NAME CONTACTPERSON PHONE <br /> ca cz¢ Ej UNKNOWN <br /> c2 a ADDRESS <br /> ir <br /> �d <br /> STREET CfTV STATE rp <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> (ra�33�/33 <br /> a ADDRESS <br /> � <.S'• C� Cee � �r 9.� C7 <br /> TREET CRY CpUMy p <br /> V5 CROSS STREET <br /> LCD <br /> a LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> Z <br /> z 7pS <br /> w REGIONAL 130ARD PHONE <br /> as <br /> C. GJq ( ) <br /> NAME QUANTITY LOST(GALLONS) <br /> w <br /> UNKNOWN <br /> m z (2) <br /> (/7 <br /> UNKNOWN <br /> Lu <br /> DATE DISCOVERED �j HOW DISCOVERED INVENTORY CONTROL 0 SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> M C,iul D / v v E:] TANK TEST TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Su M M D o v v UNKNOWN REMOVE CONTENTS F-] REPLACETANK a CLOSE TANK <br /> O HAS DISCHARGE BEEN STOPPED? REPAIR <br /> REPAIR TANK � REPAIR PIPING CHANGE PROCEDURE <br /> o RYES �NO IF YES,DATE M M .1 al v (Dy, LT OTHER ad :hz-�� <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> a O TANK LEAK UNKNOWN OVERFILL Q RUPTURE/FAILURE SPILL <br /> PIPING LEAK OTHER E] CORROSION UNKNOWN OTHER <br /> w w CHECK ONE ONLY <br /> 0 UNDETERMINED SOIL ONLY GROUNDWATER [:] DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Q f NO ACTION TAKEN r PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED a POLLUTION CHARACTERIZATION �� <br /> j y F-] LEAK BEING CONFIRMED a PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS �-• <br /> O REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) 0 CLEANUP UNDERWAY V <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) <br /> (�BACXFMM" REMOVE FREE PRODUCT(FP) ENHANCED BIODEGRADATION(IT) <br /> W Q F-1CAP SITE(CD) EXCAVATE&TREAT(ET) BUMP 8 TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> O CONTAINMENT BARRIER(CB) F NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> �F-] VACUUM EXTRACT(VE) F--] OTHER(OT) <br /> z t'GL r-f{1e✓ �I tP LLJ <br /> y� GG(/l <br /> HSC oe(+vest <br />