UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENC RVICES FOR LOCAL AGENCY USE ONLY REPORT BEEN FILED? I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE YES NO YES ❑ NO REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF REPORT DATE 71oy SE a THE HEALTH AN AFTY CODE, M c,M Z 5D / v SIGNED NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE ¢ REPRESE COMPANY OR AGENCY NAME ❑ OWNER/OPERATOR ❑ REGIONAL BOARD CL LOCAL AGENCY OTHER Lu ¢ ADDRESS STREET� \ C�c� C4Q s�c� STATE ZIP w NAME CONTACTPERSON PHONE z C C%//E c ❑ UNKNOWN /�f7 /PKC !`� �f 4! (�� 7,7{ �S a ADDRESS .ti c. ¢ STREET CRY STATE ZIP FACILITY NAME(IF APPLICABLE) OPERATOR PHONE y77 L S-7ADDRESS s?RE _ OC ��J �SYsoTGc�pllir� � ET crrr couHTv ZIP N CROSS STREET /� Z LOCALLAAGENCY AGENCY NAME /l CONTACT PERSON PHONE Lu wZ c}G1n,�C� Lr/`7 C �� FG/ lY"h I (ZC i C ) �c w wo REGIONAL BOARD PHONE Q.a y (1) NAME QUANTITY LOST(GALLONS) 0 Lu / Z 0 �� L %iz! ❑ UNKNOWN C-0> (2) mZ ❑ UNKNOWN Z DATIF DISCO ED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS (v v ❑ TANK TEST TANK REMOVAL ❑ OTHER DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) j M M D .1 yl y l7rUNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK 0 HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE o ❑ YES ❑ NO IFYES,DATE M M D D yl y ❑ OTHER SOURCE OF DISCHARGE CAUSES) C< ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL U ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER w w CHECK ON v UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY F NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION U ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 8 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) IgE BACK FOR DETA A o Q CAP SITE(CD) ❑ EXCAVATE 8 TREAT(El) ❑ f UMP 8 TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) Q a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) O VENT SOIL(VS) ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) .�ecess��' z4 --cLu iao veo Cp..'fs,,, ,ww��r, ats �ui.��/ 6y -w � 47 o U HSC 05(11/89)