UAR/PROP 65 PRE 2019 - Laserfiche WebLink

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cN-v65 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 .1 HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE� DISTRIBUTION SHOWN ON THE INSTR CTION S ET ON THE BACK PAGE OF THIS FORM REPORT DATE (1 Ty a M Z'I `T � S NFD �z DATE NAME OF INDIVIDUAL FILING REPORT PHONE Ili U jk.SIPNATURE .St'ZRy �(osKioK� (Zo9)41(x8-1Zo l2 4 wREPRESENTING OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME p� u L LOCAL AGENCY OTHER SC,1,1ti u1b.. �tri cc ADDRESS Z{Al.S N. Swn SocL�u�� - Con, gszo STREET CITU STATE ZIP w NAME CONTACT PERSON 1_ PHONE C zC `LA m ❑ UNKNOWN 3 O<a ADDRESS f� �y w t5lb w L(I!" P2fteld 9 CavlGoU,GI 4�S� I TR CITY STATE IP FACILITY NAME(IF APPLICABLE) OPERATOR PHONE o I S �-�c� o�, 1SL�1 Nocb (z0 ) < ADDRESS gti3\S w�a�c�r�oo Roo,. Stout-oma s�.>,..,1oCr.qu��, gsz.os w STREET CITY COUNTY 1 ZIP CROSS STREET �d w qq O LOCAL AGEN� AGENCY NAME CONTACT PERSON PHONE z w w REGIONAL BOARD PHONE < W C,2> ( ) W NAME QUANTITY LOST(GALLONS) w p I Z J CTCL.' 0 C. UNKNOWN a z (Z) ❑ UNKNOWN DATE DISCOVERED Q , I HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING E] NUISANCE CONDITIONS Z w ` M1 Z-MI o DI%DI `Yj"�' Y ❑ TANK TEST TANK REMOVAL ❑ OTHER < DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) m a UNKNOWN ❑REMOVE CONTENTSCLOSE TANK&REMOVE ❑REPAIR PIPING w M M D D Y Y LIN >O HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK E::]CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE o YES [:] NO IF YES,DATE M Z MI O D D G Y L; Y REPLACE TANK ❑ OTHER LD w SOURCE OF DISCHARGE CAUSE(S) ccIn ❑ TANK LEAK UNKNOWN F__] OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL Ocn U ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER w w CHECK ONE ONLY U UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY w F-] NOACTION TAKEN F7 PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED E:] POLLUTION CHARACTERIZATION jy LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY 11POST CLEANUP MONITORING IN PROGRESS U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) J (SEE BACK FOR WTAIS) a Z ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) 5 O wl w a F] CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ -T1RE_ATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) r cc ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) Q\/CI--[C(►A�/G � 1^ v ui m 0 Q U HSC 0.5(RSO)