Laserfiche WebLink
kj <br /> UNDERGROUND STORAGE TIC UNAUTHORIZED RELEASE (LEAK)1 CTAMINATION SITE REPORT <br /> F <br /> RGENCY HAS STATE OFFICE OF EMERGENCY SERVICES AOR LOCAL AGENCY:,US�;ONLY <br /> YES z REPORT BEEN FILED 7 0 YES .)}IEAEBY CEI{flFy 7FlAT I ANF p pF$(( }pTD GOVERNMENfi FMPlOYE6 AND T}{AT t}{AVE' <br /> REPORT DATE fiPORTED;THI �I8-�{6Ui)S:PURSUANT TO SECTION 25180 7 OF:: <br /> CASE TH <br /> Ois <br /> Ml M d 7 0 17,1 Y <br /> NED ....;4 DATE <br /> AME OF INDfVIDUAL FILING REPORT PHONE SIGN <br /> IEvE�lr� <br /> m • <br /> w REPRE ING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY N E <br /> p LOCAL AGENCY ❑ OTHERLu <br /> cc ADDRESS <br /> STREET any <br /> STATE <br /> NAME CONTACTPERSON PHONE ZIP <br /> m <br /> Z `�YEST4t/ / S7�y[/� ❑UNKNOWN ii [I W Fir-fit { 700 <br /> a <br /> IL ADDRESS <br /> 7g IF `1,1';K041Ge AVE- 0-46e- <br /> STREET " CRr STATE 21P I <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> fz/�Ffsro ver f <br /> ADDRESS V <br /> �G- <br /> w W490STREET Cm. _ COUNIY ZIP; <br /> y CROSS STREET TYPE OF AREA MERCIAL INDUSTRIAL TYPE OF BUSINESS <br /> � C�RUQ E] RETAIL FUEL STATION <br /> L+�itldsi� ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> LU <br /> 41a- 3�{ <br /> ui w REGIONAL BOARD <br /> PHONE <br /> tu (�) vn,.*,p r4p� NAME QUANTITYLOST(GALLONS) <br /> w y�7 <br /> p 'WC+! ❑ UNKNOWN <br /> (2) Ct <br /> _ ❑ UNKNOWN <br /> i DATE DISCOVERED G�71 ( <br /> HOW DiSCOVERs D ❑ I ORY CONTROL E] SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> LLJ <br /> M OD D ` r C7 TANK TEST TANK REMQVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M D o y y UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANKCLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p ❑ YES ❑ NO FYES,DA,7 MI MI DI D r y D OTHER <br /> w SOURCE OF DISCHARGE TANKS ONLYICAPACITY MATERIAL CAUSES} <br /> ❑ TANK LEAK UNKNOWN GAL.' ❑ FIBERGLASS . ❑ OVERFILL ❑ RUPTUREiFAILURE <br /> ❑ PIPING LEAK AGE YRS �—f/STEEL ❑ CORROSION [?TUNKNOWN <br /> ❑ OTHER UNKNOWN OTHER ❑ SPILL 0 OTHER <br /> ww CHECKONEONLY _ <br /> va <br /> 21"UNDETERMIN£D ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY.IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> y N <br /> cc a ❑ S INVES71GA71gN IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U ti NO AC71pN TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) ;F <br /> z ❑ CAP SITE(CD) ❑ EXCAVATE d DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 1310 DEGRADATION(IT) <br /> Lu <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE E TREAT(ET) '❑ PUMP&TREAT GROUNDWATER(GT) ❑J.REPLACE SUPPLY(RS)cc <br /> k <br /> ❑ TREATMENT AT HOOKUP(HU) - 0 NO ACTION REQUIRED(NA) ❑OTHER(OT)_ �� ��b�✓ I <br /> Fr„e �C err /as�F.Ss�r6s�-r « �� �pEc��,ep7 -rb DE22;j9,441e1_1CTt�ar <br /> .fi�T✓i�� ANU E�c'ij~�� C�rV7'/d��e�I�Ty4�/ . /4Fv/�E.d /3't '7 /F <br />