Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)If CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 <br /> ❑ YES No ❑ YES No ;1HEREBYCERTIF.YTHATI:HAVE 151NFORMATIONACCORDINGTOTHE <br /> REPORT DATECASE OISTAI THE INSTRUCTION SHETEON THE BACK PAraE OF THIS F M <br /> c <br /> . <1 Y <br /> NAME OF INDIVIDUAL FILING AtPORT PHONE S9G RE <br /> tFm <br /> LOU RE;�E=CY <br /> ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY N�AMME.,f r( cd-, , <br /> o ❑ OTHER P✓8�-lL� `r� �-' �R�iG�yf//�Li�I/���I�lTI�L <br /> cc ADDRESS <br /> �� <br /> STREET CRY STATE ZiP <br /> 1 NAME x I J CONTACTPERSON PHONE <br /> aN <br /> /V <br /> UNKNOWN � N � R Z Z— <br /> O< ADDRESS4 Q� <br /> LU <br /> STRE <br /> CITY STATE P <br /> FACILITY NAME(F APPLICABLE) OPERATOR PHONE <br /> wuv <br /> a <br /> ADDRESS <br /> 1-14vY '-Sb412"A0 <br /> 0 <br /> N CROSS STREET Courrry P <br /> z LOCAL AGENCY AGENCY NAME CONTACT PERSON <br /> PHONE <br /> 5,4I4 pvec.e 46ev <br /> Lu z3� <br /> w Lu REGIONAL BOARD PHONE <br /> as <br /> U w () NAME QUANTITY LOST(GALLONS) <br /> toE?tNKNOWN <br /> N 0 <br /> �z <br /> N <br /> UNKNOWN <br /> F- DATE DfSCOVEREO HOW DISCOVERED <br /> _ ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w ❑ <br /> w O� &I oI Y r ❑ TANK TEST NK REMOVAL OTHER <br /> r- <br /> DATE DISCHARGE BEGAN <br /> a METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w 01 r A UNKNOWN ❑REMOVECONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> v HAS DISCHARGE BEEN STOPPED 7 ❑ P <br /> REPAIR TANK ❑CLOSE TANK&FILL IN ACE ❑CHANGE PROCEDURE <br /> g ❑ YES ❑ NO IF YES,DATE M{ o r Y ❑REPLACE TANK ❑OTHER <br /> p SOURCE OF DISCHARGE CAUSE(S) <br /> 00)w <br /> ❑ TANK LEAK UNKNOWN ❑ OVERFILL 13R REAFAILURE ❑ SPILL <br /> � <br /> v ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> LU m a CHECK ONE ONLY <br /> co CL ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> 01 <br /> CHECKO NLY <br /> Z Z NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> j m ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ <br /> MM eActt ran t>ETusj EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> a <br /> Lu <br /> 0 0 ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> uj <br /> ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> /PEVtOAV O< 5401 L. <br /> K�Ettrn-r�L <br /> w Ca �4.4�-�/. 7'i ( <br /> o A,-4,7W r--: �'Yi n��}-r-�.eF'�rV� � '=`o F GdN� T✓V.�J�cr <br /> ,�,E1� 8Y .4tf�,4vpRZ'�7 ,Eee.G,,4? 0�, <br /> "SC 05(TV <br />