UAR/PROP 65 PRE 2019 - Laserfiche WebLink

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FIL COPY UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY ❑ YES NO REPORT BEEN FILED 7 YES ❑ NO I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE� � DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. ' REPORT DATE CASE.1 6 M 9 MI JT Y SIGNED DATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE m <<1�-�l.l� cam ) Ybq-aYy w REPRESENTING ❑ OWNERIOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME pLOCAL AGENCY ❑ OTHER Cc ADDRESS 0 `�• U*�TREET STATE C� ZIP Lu N M CONTACT PERSON PHONE co Z h(,, UNKNOWN COL as AD I ka-\L ESS cn �j� a P�T ALU(' w � q Jpo CLQ Twt CIS`/- - " " - ` TAE �� IP� Q FACILITY NAME(IF APPLICABLE) OPERATOR PHONE tael e,%A a ADDRESS U"� A JC�� c o G sZl 1 VI Yt `64RELT" CITY �Qa 9u'N COUNTY ZIP = CROSS STREET LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE zco z w ( ) U w w REGIONAL BOARD PHONE J< < ( ) O m (1) NAME QUANTITY LOST(GALLONS) W ZO ❑ J UNKNOWN a m> (2) I z ❑ U) UNKNOWN Z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORINGNUISANCE CONDITIONS ❑ O W (),IMI MI ODI DI Y �Y ❑ ❑ ,5y�1.' � TANK TEST TANK REMOVAL OTHER a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) m a � O S ❑ UNKNOWN E:]REMOVE CONTENTS E:]CLOSE TANK&REMOVE EPAIR PIPING w M M D� D Y Y p HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE F7CHANGE PROCEDURE U U) YES ❑ NO IF YES,DATE ❑REPLACE TANK ❑ OTHER M M D D Y Y SOURCE OF DISCHARGE CAUSE(S) Lu cr L ❑ TANK LEAK F-] UNKNOWN F-1OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL ON U PIPING LEAK ❑ OTHER Y CORROSION ❑ UNKNOWN ❑ OTHER w w CHECK ONE ONLY 7 v SOIL ONLY GROUNDWATER DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) UNDETERMINED ❑ ❑ ❑ CHECK ONE ONLY Lu F-] NOACTIONTAKEN F-] PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION a ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS U y ❑ REMEDIATION PLAN a CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) 0 CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) J (SEE SACK fOR DETAlS) a z ❑ CAP SITE(CD) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) w- wF- 0 F7 CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) El VENT SOIL(VS) ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) ��Qe S tlA(.Jt7k �� tA- OCA' cta orktz far hv.4- efo C.0-as (zke ck . O U HSC 05(890)