UAR/PROP 65_PRE 2019 - Laserfiche WebLink

Home Browse Search

Avg s UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT EMERGENCY i HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY REPORT BEEN FILED? I HEREBY CERTIFY THAT 1 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 CASEA THE HEALTHjAND SAFTY COD4 C (� ��.._.. Ll L' M ° M o D v Y STN D DATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNAT' RE REPRESENTING F7OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME a ©'LOCAL AGENCY ❑ OTHER S �G �� ! 7� '•J+ w ¢ n�e �� ADDRESS ©O OF Ao 1. /'L.`T i I ✓� / STREET CITY $TATE ZIP ZLu NAME �^�yCONTACT PERSON J '` PHONE q�J j Sa GK �{L (� �C_i'Rty! ❑ UNKNOWN 1�� ri�L� �Y � { ` �J 7 OQ ADDRESS /� � � ' Lu EL �" �f STREET CRV STATE ZIP FACILITY NAME(IF APPLICABLE) OPERATOR PHONE --S-,u os VADDRESS �r YtGC. STREET CRV COU NTV ZIP N CROSS STREET 0 LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE w REGIONAL BOARD PHONE G ( ) (1) NAME QUANTITY LOST(GALLON w p J N✓ j�` �/I�A UNKNOWN O ZV U 2 ") /l �� `^�l�Gt rif/�--- ❑ UNKNOWN Z /DATE DISCOVE�R�EjD /` HOW DISCOVE D F-] INVENTORY CONTROL SLIOSURFACE MONITORING E:] NUISANCE CONDITIONS M M `� D t D �v y ❑ TANK TEST ❑ TANK REMOVAL OTHER m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) w M M D D v y Iw UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK O HAS DISC E BEEN STOPPED? if/7� ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE YES ❑ NO IF YES,DATE 'M M /D D v� v ❑ OTHER r (�J_I 9 SOURCE OF DISCHARGE CAUSE(S) a ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE FAILURE SPILL U �PINGLEAK 1-1 OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER w w CHECK ONE ONLY U ❑ UNDETERMINED [o SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK 0 ONLY cn w NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS v ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ENHANCED 810 DEGRADATION(IT) IgE BACK r08 Att3l 0 Q ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) F-1f,UNP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) LU Qa ❑ CONTAINMENT BARRIER(CB) ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) VACUUM EXTRACT(VE) { OTHER(OT) �� Q s-Ce S C m�'l�i'[�• �.,�i -UZcG - q � e� �r.�C.�1i�tic�' HSC os(11"