Laserfiche WebLink
tt 76 <br /> I <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)1 CONTAMINATION SITE REPORT p <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL°°`AGENCY'USE'ONLY ] <br /> REPORT BEEN FILED 7 <br /> [� YES NO [ YES XNO ]HEREBY CERT)FYTHAT F HAVE DiSTRIBUTED.THIS INFORMATION ACCORDiNG,TOTHE <br /> DISM K)N SHOW N SHEET ON THE BACK PAGE OFTH ORM <br /> REPORT DATE CASE <br /> �I MI Cd zi .� :.... <br /> ...,..; ..., DAT£... :> <br /> NAME OF INDIVIDUAL FILING REPORT I PHONE, 'f SIGN RE <br /> w REPRESENTING 0 OWNER/OPERATOR 0 REGIONAL BOARD COMPANY OR AGENCY NAME j <br /> O LOCAL AGENCY 0 OTHER IMV �� <br /> w <br /> cc A DRESS <br /> G101�51 /t/ :5v-�i S'r <br /> STREET CFTY STATE zip, <br /> J NAM�E1 CONTACT PERSON PHONE <br /> i El—�J�b��G��f� � �L� UNKNOWN <br /> Q ADDRESS '7' <br /> L 7 <br /> STREET CRY STATE "p <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS <br /> y <br /> Ow V STREEEt GRY COUHTr ZIP <br /> y CROSS STREET <br /> ? LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> zw . eN333 <br /> w U <br /> L ww9 REGIONAL BOARD PHONE <br /> CL <br /> U <br /> W (S) ���+�� I NAME QUANTITY LOST(GALLONS} <br /> LU <br /> //**p Yifv ET"UNKNOWN <br /> Z <br /> a0 <br /> w , <br /> m> {� <br /> y- <br /> �' � UNKNOWN <br /> z DATE DISCOVEREDHOW DISCOVERED I VENTORY CONTROL SUBSURFACE MONITORING. NUISANCE CONDITIONS <br /> ui <br /> uI o r r 0 TANK TEST vNK REMOVAL OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHAR (CHECK ALL THAT APPLY) <br /> UNKNOWN 0 REMOVE CONTENTS CLOSE TANK&REMOVE 0 REPAIRPiPING <br /> HAS DISCHARGE BEEN STOPPED? 0 REPAIR TANK 0 CLOSE TANK&FILL IN PLACE 0 CHANGE PROCEDURE I { <br /> a 0 YES 0 NO IF YES.DATE 'Al <br /> j r r ❑REPLACE TANK 0 OTHER <br /> Lij SOURCE OF DISCHARGE CAUSE(S) \ } <br /> 0 TANK LEAK UNKNOWN OVERFILL 0 RUPTURElFAiLURE 0 SPILL <br /> S <br /> 0 cO 0 PIPING LEAK 0 OTHER I; 0 CORROSION 0 UNKNOWN 0 OTHER <br /> N wa CHECK ONE ONLY <br /> 8 0 UNDETERMINED 0 SOIL ONLY 0 GROUNDWATER 0 DRINKING WATER-{CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z0 NO ACT14N TAKEN 0 PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED 0 POLLUTION CHARACTERIZATION _ <br /> LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> cO y 0 REMEDIATION PLAN Q CASE CLOSED{CLEANUP COMPLETED OR UNNECESSARY) 0 CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) 0 EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) 0., ENHANCED BIO DEGRADATION(IT) <br /> 02 CAP SITE(CD) 0 EXCAVATE 8 TREAT(ET] 0 PUMP&TREAT GROUNDWATER{G 1)0' REPLACE SUPPLY(RS) <br /> LU� <br /> a ❑ CONTAINMENT BARRIER{CB) 0 NO ACTION REOUIRED(NA) 0 TREATMENT AT HOOKUP(HU} 0', VENT SOIL(VS) <br /> 0 VACUUM EXTRACT(VE) 0 OTHER(OT) <br /> criof Soles iCcG� „�Pv� �"•�sN�/�Ffrcc..i i-/Y/3it �� ��ossr�'��, <br /> -441:6�lcl -ra .T-.y,— . <br /> L 4-A�f CAfA -7-Eo S.*T,-- /arA i4 rSLOSc - c.�`7"HER �TL� 5/r«�►r� ll-e <br /> � MSC 0516�l <br /> a <br />