Laserfiche WebLink
i <br /> u <br /> ) <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT I <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES :FOR LOCAL AGENCY USEONLY '. '1. � <br /> REPORT BEEN FILED? 'HEREBY CERTIFYTHATi HAVE DISTRIBUTEDT ISIN FORMATION ACCORDING TOTHE <br /> E] YES NO YES ❑ NO DISMISUTION SHOWN ONTHEWSTRUCTION ET ON THE BAC AGEOFTH.GFORM � <br /> REPORT DATE CASE A <br /> SIGKED DATE T <br /> NAME OF INDIVIDUAL FILING REPORT PHONE / p' SIGNATURE { <br /> m I✓l A ✓ EJO <br /> ) <br /> I <br /> w REPRESENTING ❑ OWNERK)PERATOR ❑ fAEGIONALBCAIID COMPANY OR AGENCY NAME <br /> R LOCAL AGENCY ❑ OTHER _N• <br /> x ADDRESS <br /> I D 1 8 O SfREf! L./ cm ` srATtl/' > =gyp <br /> j NAMEC - CONTACT PERSON rPHH-ONE �/ <br /> U¢ O J Pi �/ �❑ UNK WN .S V7�O) ! Q <br /> wy ADDRESS AN7'/ftdG yd'7 �T /� CA <br /> ¢ /'f STREET Cm /V�/ STPTE Ip <br /> FACILITY NAME(IF APPLICABLE) OS c,s//4W OPERATOR PHONE <br /> `a ADD S`S�``�C�r` eV �f- `V ot-% s S (5/017149,'o <br /> 2Scm 3.7 <br /> w <br /> y CROSS STREET <br /> U. <br /> LOC ALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> ) Gg Z i <br /> w� REGIONAL BOARD PHONE <br /> ` c vg toGB c ) <br /> y (1) NAME QUANTITY LOST(GALLONS) 'iI <br /> ¢ O VN lxS ❑ UNKNOWN <br /> Ho m <br /> y ❑ LINKNpWN <br /> z DATE DISCOVERED / HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCECON <br /> Jr ❑ TANKTEST TANK REMOVAL ❑ OTHER �I( <br /> lDATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a O- <br /> - ❑ UNKNOWN REMOVE CONTENTS ❑CLOSE TANKA REMOVE ❑REPAIR PIPING II N <br /> w u o .1 r I <br /> HAS DISCHARGE BEEN STOPPED? - ❑REPAIR TANK ❑CLOSE TANK E FILL IN PLACE ❑CHANGE PROCEDURE <br /> ❑ YES ❑ NO IF YES,DATE <br /> ml d ❑REPLACE TANK - 'OTHER <br /> o d r <br /> SOURCE OF DISCHARGE CAUSE(S) `I <br /> TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> y O ❑ PIPINGLEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER I <br /> ww CHECK ONE ONLY <br /> O UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY- <br /> wy ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION �? <br /> UN ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS h <br /> REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) E:] CLEANUP UNDERWAY ', <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATK)N(IT) I <br /> J ISFf%�lfACET.VaI <br /> o p ❑ CAP SITE(CD) F, . EXCAVATE 8 TREAT(ET) ❑ PUMP E TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w Y ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) )k <br /> ¢a <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) fI <br /> ll ✓l�e, U 6S57s V`6U t,o✓eon 9 A/ fi44I e - 5 i,Ac <br /> assessN,e w. ?-L be re-1 <br /> 3 ei n d e As ✓eg u,r n.ecE <br /> RSC W IASQ, <br />