Laserfiche WebLink
C,i- t <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> If <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES' FOR LOCAL AGENCY USE ONLY <br /> ❑ YES NO REPORT BEEN FILED 7 ❑YES ✓ NO I HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT.EMPLOYEE AND THAT I HAVE: <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORT DATEpASE s THE HEALTH AND SAFTY CODE <br /> M M D Y v SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> 0 REPRESENTI G OWNER/OPERATOR REGIONALBOARD COMPANYORAGENCYN <br /> ir <br /> Oa �AGENCY OTHER <br /> w <br /> cc ADDRESS <br /> 00 <br /> STREET C(TY STATE ZIP <br /> w NAME CONTACTPERSON PHONE <br /> c m Sal (�U <br /> z ` UNKNOWN e 6 <br /> gL ADDRESS ` <br /> % q �y ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> �S <br /> GtS d S D <br /> �Q U � <br /> ADDRESS 1-/^' C� //� <br /> �J O a ✓L STR;EEf' J I CSC/RYl COUNTY � OJ <br /> ur CROSS ST EET I /; <br /> Z LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> Nw / <br /> !�G �rilrV <br /> _ <br /> w(wj REGIONAL BOARD /PHONE <br /> NAME QUANTITY LOST(GALLONS) <br /> w <br /> 0 UNKNOWN <br /> z (2) <br /> \ 0 UNKNOWN <br /> Z DATE DISCOVERED HOW DI VVf a INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> 2 0 M �D D V V <br /> � RED <br /> TANK TEST TANK REMOVAL OTHER <br /> M <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M M D D V Y <br /> UNKNOWN Fl RE OVE CONTENTS REPLACE TANK CLOSE TANK <br /> O HAS DI ARGE BEEN STOPPED 9 // �tYnRREE`PAIR TAN/K�'�/� El <br /> REPAIR PIPING CHANGE PROCEDURE <br /> o S YES � NO IF YES,DATE mi M D o yv v 'TME R "_�, <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ja 0 TANK LEAK [ KNOWN 0 OVERFILL 0 RUPTURE/FAILURE � SPI <br /> U ❑ PIPING LEAK �THER CORROSION UNKNOWN THER y( <br /> w ww CHECK ONE ONLY <br /> U UNDETERMINED SOIL ONLY GROUNDWATER E DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w ACTION TAKEN O PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED E:] POLLUTION CHARACTERIZATION <br /> C: <br /> Ir LEAK BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERWAY [::] POST CLEANUP MONITORING IN PROGRESS <br /> REMEDIATION PLAN F-� CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) E] CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) F—] EXCAVATE 8 DISPOSE(ED) 0 REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> (BEE BACK FOR OEMA-9 <br /> W 4 F-] CAPSITE(CD) 71EXCAVATE&TREAT(ET) El PUMP 8 TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> Qa 0 CONTAINMENT BARRIER(CB) n N1�ACT]ONREQUIRED(NA) TREATMENT ATHOOKUP(HU) 0 VENTSOIL(VS) <br /> VF-] VACUUM EXTRACT(VE) ER(OT) vax <br /> c�57i`gi s 3-,;t Y 0, <br /> g Tum. T'G',rt 2. �ass ec-C <br /> —05(ive% <br />