Laserfiche WebLink
i <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)l CONTAMINATION SITE REPORT <br /> EMERGENCY - HAS STATE OFFICE OF EMERGENCY SERVICES FOR.LOCALAGENCY USE ONLY ,' ' <br /> O REPORT BEEN FILED? O YES O NO I HEREBY CERTIFY TRAT 1 AM A OESIGNATED GOVERNMENT EMPLOYFE AND THAT!HAVE' <br /> vEs No REPORTED THIS:INFORMATION TO LOCAL,OFFICIALS PURSUANT..TO:SECTION:25180.1 OP: <br /> REPORT DATE p q CASE♦' THEHEALTH ANO SAFTYCODE <br /> /.10.1 I -3o G y / Y - SIGNED � DATE � <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> (2 �0i l (�)y69k--3V6',kj <br /> a REPRESENT G ❑ OWNERIOPERATOR O REGIONAL BOARD COMPANYOR-A7GGENCV NAME n //- <br /> p LOCAL AGENCY OTHER c57at?�/-aa L/ /J 1a9 h�/C IcO � „ Spnf — k <br /> 0 <br /> ADDRESS / <br /> ( 6 D/ [,�`i Nt!! //"�/"� �7 CITY J �G/c%L Vh STATE : V ' ZIP I"o <br /> NAME - CONTACTPERSON PHONE 6)(711 3 (pJO <br /> 1-r DY -#33 Q UNKNOWN ,�D�l/J FUI�/� ) q ll- O l3 <br /> Sy< ADDRESS 42747 <br /> M/ <br /> may)r /� , <br /> /47 , STREET �, ////n r CRY S77GC /T/ <br /> /ICV17 STATE : C,4 395-- <br /> FACILITY NAME(IF APPLICABLE) - OPERATOR - PHONE exi-3 YO <br /> 0 <br /> Com W 3 3 Soti n Fu ri- yo Y3 <br /> ADDRESS <br /> ` 957o r— <br /> cP <br /> / . �7 ' courm qS0 <br /> y CR,OSS{SSTREET'[ TYPE OF AREA OCOMMERCIAL INDUSTRIAL O RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> / 4 <br /> /7 v r 7 /ems Q RESIDENTIAL.. O OTHER O FARM ER i <br /> m LOCALAGENCY AGENCYNAME: 'Sw/CPS NTACT PERSON _ �PH�O3.NEE. <br /> w -3V&,F <br /> ww REGIONAL BOARD - PHONE <br /> C2cJ CB �ordon /3o <br /> U) NAME - QUANTITY LOST(GALLO ) { <br /> e 0 UNKNOWN <br /> wy (� k <br /> - .8e�sem <br /> NKNOWN <br /> 1- DATEDISCOVERED HOWDISCOVERED O I NTORYCONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> M M o o Y y O TANK TEST Z :TANK REMOVAL O OTHER <br /> DATE DISCHARGE BEGAN 'METH OD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY)' <br /> w M- M u D v y UNKNOWN REMOVECONTENTS O REPLACETANK CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? - -- REPAIRTANK O REPAIRPIPING CHANGE PROCEDURE <br /> p O VES O NO IFYES,DATE M, M o D y y OTHER <br /> w SOURCE OF DISCHARGE . - TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> O TANK LEAK! UNKNOWN 4/,e_ <br /> IOIc-:GAL. O FIBERGLASS O OVERFILL 'O RUP AZURE <br /> O PIPING LEAK AGE VRS O STEEL O CORROSION _. UNKNOWN F[ <br /> O OTHER UNKNOWN O OTHER O SPILL O OTHER [ <br /> ww CHECK ONE ONLY Ir <br /> U a O UNDETERMINED - SOIL ONLY GROUNDWATER O 'DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> r y <br /> CHECK ONE ONLY <br /> a O SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) O CLEANUP:IN PROGRESSO SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) EE� <br /> NOACTIONTAKEN O POST CLEANUP MONITORING IN PROGRESS O NO FUNDS AVAILABLE TO PROCEED O EVALUATINGCLEANUPALTERNATIVES { <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) _ II <br /> 0 <br /> 5O CAP Bar(DID) . O EXCAVATE&DISPOSE(ED) O REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> 00 <br /> w� O CONTAINMENT BARRIER(CB) -O EXCAVATE&TREAT(ET) O PUMP&TREAT GROUNDWATER(GT) O REPLACE SUPPLY IRS) <br /> O TREATMENT AT HOOKUP(HU) D NOACTIONREOUIRED(NA) O OTHER(OT) <br /> y fhe. sib gssess nTo,t r� uirY� �o Pln`G+m//Lo 'o a4r' e VL ejr�nllw <br /> COn irAvinG�tUYI uS o',,Vt tV, his 4/' q <br /> a ea .off' S%,e of corm. of MyHfe T+ F7,6erf , <br /> H=M(4ST <br /> I <br />