Laserfiche WebLink
L019�61 <br /> UNDERGROUND STORAGE . ANK UNAUTHORIZED RELEASE (LEAK) i uONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMER NCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 <br /> ❑ ves No vES ❑ No 1HEpEBY CERTIFYTHAT} HAVE DISTRIBUTED-THIS INFbRMA710N ACCOROMG TOTHE <br /> REPORT DATE DISTRIBUTION SHOWNCN THE WSTRUCTKIN SHEET ON THE BACK PAGE OF THIS <br /> FOAM: <br /> (y CASE i <br /> �M �MI Od V Y SIGNED DATE <br /> NAME OF INDIVIOU FILING REPORT PHONE SIGNATURE <br /> w REPRES NTING ❑ ❑ COMPANY Ofl AGENCY NAME <br /> OWNER/OPEflATOR REGIONAL BOARD 1 <br /> gLOCAL AGENCY ❑ OTHER ��.(, <br /> ADDRESS 3'` Moor "`•..111 ��' JJJ <br /> ,301 IE . W � ,�ia S ' o ��-cwt, e,�4 9.5cgo a- <br /> RA E IIP <br /> w NAME CONTA/C�T-PERSON I^) J� yy� PHO/N�E (y' J �j <br /> Uzx -5 Ran o� Y a* b� �o ❑ UNKNOWN D/ . 1) I N /T / N.J,Y I L �V 1 (0 (� 7 I <br /> ADDRESS <br /> SiPEET STnTE IP <br /> FACILITY NAME (IF APPLICABLE) QPE�RATOR T �O }"1 - /) PHONE <br /> a0 ADD i41 SI W bULLYiLri"i <br /> STREET cR Y `� • D� <br /> CROSS STREET wuNry nP <br /> Z <br /> oy <br /> w LOCA; ANCV . Iq=ENCY NAME , ` CONTACT PERSON _ <br /> V` S YN ILIL ll PHONE <br /> yVl . l� caa�� lk68- <br /> w Y <br /> REGIONAL BOARD PHONE <br /> L9 c c <br /> W L11 NAME <br /> ZQUANTITY LOST (GALLONS) <br /> w <br /> F ' UNKNOWN <br /> UNKNOWN <br /> r DATE DISCOVERED �-yV HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w 8-I I d 0I O ❑ TANKTEST TANK REMOVAL ❑ OTHER <br /> M � Tl <br /> DATE DISCHARGE BEGAN r METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> s <br /> MI DI r UNKNOWN ❑ REMOVE CONTENTS 17CI CLOSE TANK & REMOVE ❑ REPAIR PIPING <br /> 0 HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIR TANK /❑ CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE <br /> in VES ❑ NO IF VES, DATE IMI 0 u 4 qr ❑ REPLACE TANK ❑ OTHER <br /> tw SOURCE OF DISCHARGE {� / CAUSE(S) <br /> ¢ j ❑ TANK LEAK 11T UNKNOWN ❑ OVERFILL ❑.,/RUPTURE/FAILURE ❑ SPILL <br /> 00 <br /> F-'] PIPING LEAK ICJ❑�� OTHER CORROSION UNKNOWN ❑ OTHER <br /> w CHECK ONE ONLY <br /> O ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER . (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK <br /> ONE ONLY <br /> w � IJ(I NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ¢ r �❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O m ❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <br /> 0o ❑ CAP SITE (CD) EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) REPLACE SUPPLY (AS) <br /> w O ❑ CONTAINMENT BARRIER (CB) NO ACTION REQUIRED (NA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br /> ¢ a <br /> ❑ VACUUM EXTRACT (VE) ❑ OTHER (OT) <br /> a `•./C 4!;, <br /> U <br /> XSC 0.51&9N <br />