Laserfiche WebLink
0,-3- <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? <br /> YES No YES NO 1 HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> +yREPORT DATE CASE a <br /> v MI MI 3J SIGNED DATE <br /> NAME OF INDIVIDU FILING REPORT <br /> PHONE <br /> / �� SIG RE <br /> mAA- <br /> REPRESENTINGF-I <br /> COMPANY OR AGENCY NAME OWNER/OPERATOR REGIONAL BOARD <br /> Q <br /> LOCAL AGENCY OTHER c <br /> o ADDRESS, �, Ole <br /> 4 e � � 1 - <br /> 3 a(I/ ('�/STREwETc~+`- CITY STATE <br /> ZIP <br /> wE /y <br /> C( CONTACT PERSON PHONE <br /> z i KNOWN �(3vk <br /> 0- ADDRESS AA <br /> Q <br /> Lu <br /> '1 o ^/���yy�� l'C CIU re., �S � i v <br /> CI STATE pp <br /> FACILITY NAME(IF APPLICAB ) OPERATOR PHONE <br /> 3 c <br /> a ADDRESS Y <br /> ZIP <br /> o /' aE�Err CJI! I Ud . cls `— �— 'C'C0.ti'o <br /> CROSS STREET <br /> �C - , -� k�=�c C> <br /> LOCALAGENCYu AGENCY NAME CONTACT PERSON PHONE <br /> z� <br /> z w <br /> w U _ --j <br /> - <br /> w w REGIONAL BOARD PHONE <br /> O <br /> (iy NAME QUANTITY LOST(GALLONS) <br /> Lu <br /> z S S UNKNOWN <br /> Q J V <br /> H <br /> m> (2) <br /> 6- /1_ \ )< UNKNOWN <br /> Z ,,D�rAA�TE DISCOVERED HOW DISCOVERED INVENTORY CONTROL � SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lu <br /> l.!M' �MI ` D! r 3r ❑ TANK TEST [:] TANK REMOVAL OTHER f 6�e t� iG <br /> ul <br /> - �.�e�+�+• `ms�' <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Q UNKNOWN F-1 REMOVE CONTENTS CLOSE TANK 8 REMOVE a REPAIR PIPING <br /> w M M D D Y Y <br /> 0 HAS DISCHARGE BEEN STOPPED 7 a REPAIR TANK F7CLOSE TANK&FILL IN PLACE E:]CHANGE PROCEDURE <br /> o ❑ YES 1)6NO IF YES,DATE M M) DI DI r y E::]REPLACE TANK OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> L)a ❑ TANK LEAK UNKNOWN ❑ OVERFILL O RUPTURE/FAILURE ❑ SPILL <br /> in O O PIPING LEAK OTHER CORROSION $;a, UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> In a- <br /> U 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 /> wart <br /> �ar �c� LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> U 1❑- REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) E:] CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) F7EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ISEE BACK IDR DETAlS) <br /> a z CAP SITE(CD) EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ <br /> o REPLACE SUPPLY(RS) <br /> O <br /> ❑ <br /> w <br /> CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) F-1TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> )._. <br /> w¢ <br /> VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> In <br /> z <br /> z <br /> Lu <br /> 0 <br /> U <br /> HSC 0.5�&9C; <br />