Laserfiche WebLink
C) . ui-d <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERG Y SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 1 HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> F7 YES NO VES ❑ NO <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE CASE* <br /> IM ' MI Z r SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE IGnTU_RE <br /> ��1�pVl 0 Vti (Z(�I) I N�6� a�f CA <br /> REPRESENTING OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME 1^ '^I,�n/��/�-t�/—J 1�,.Iy"n <br /> gLOCAL AGENCY ❑ OTHER � 6 u nV IV 0YHe LIAI 1 f aj <br /> DRESS <br /> 3o4 E. C-A q52-02-- <br /> STREET CFTV STATE ZIP <br /> w NAME - 1 CONTACTPERSON PHONE <br /> co <br /> Z¢ KA"(V UNKNOWN <br /> °CL <br /> a ADDRESS <br /> CA <br /> w ► JGI.S '`STREET CITY <br /> STATE a p <br /> FACILITY NAME(IF APPLI ABLE) OPERATOR PHONE <br /> W K) -Save, L4LJ-(03L-10 <br /> UADDRESS <br /> 205-1 S• �� L � ST a52ao <br /> W STREET CfTY COUMTr ZIP <br /> vi CROSS STREET - <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w ST - �nvl�o v�w e*v+-21 � 4e.A,-H,,i MG� oLyle ori o <br /> w it REGIONAL BOARD PHONE <br /> N (i) NAME QUANTITY LOST(GALLONS) <br /> W O <br /> Z> C��DI I Y I UNKNOWN <br /> Q J <br /> In <br /> CD <br /> > (2) <br /> D <br /> JQy <br /> UNKNOWN <br /> r- DATE DISCOVERED 2 HOW DISCOVERED ❑ INVENTORY CONTROL a SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> w I MI ` MI E) ✓o� r� r ❑ TANK TEST ❑ TANK REMOVAL OTHER bQ'� 11 <br /> a <br /> © DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL TPtAT APPLY) <br /> a �r <br /> 21 <br /> UNKNOWN ❑REMOVE CONTENTS p,� ,CLOSE TANK 6 REMOVE ❑REPAIR PIPING <br /> `L .1 16011 01 DI Yl Yl l <br /> >O HAS DISCHARGE BEEN STOPPED 4 ❑REPAIR TANK CLOSE TANK b FILL IN PLACE ❑CHANGE PROCEDURE <br /> o YES ❑ NO IF YES,DATE l rA O MI V o r r ❑REPLACE TANK O OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ja ❑ TANK LEAK UNKNOWN -1OVERFILL RUPTURE/FAILURE ❑ SPILL <br /> ON v ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN O OTHER <br /> w w CHECK ONE ONLY <br /> �a <br /> G 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 /> UP <br /> s I ❑ LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> Z)co <br /> O ❑ REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE d DISPOSE(ED) F-] REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> J (SEE MGK FOR OET,LLS) <br /> E Z ❑ CAP SITE(CO) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> 5 O <br /> Lu <br /> w< ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) OTHER(OT) <br /> Z 'r-2�t.,�1� - kV CkOtk`W11 Vl C -Hila <br /> uj <br /> V1�u�� c��, Pic-1-��- b�- �.o►�.-�civv�. <br /> O <br /> U <br /> HSC 0.5("0) <br />