Laserfiche WebLink
qo- t,L- 3 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)!CONTAMINATION SITE REPORT <br /> EMERGENCYHAS STATE OFFICE OF EMERGENC�f'SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? / I HEREBY CERTIFY THAT 1 AMA DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> ^Y <br /> 7 YES NO ES 0 No REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> R�EjPOR`'T�DLATE CASE K THE H TH D DI <br /> CODE. /J�t /j <br /> PATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATU <br /> m <br /> O REE ING F70WNERIOPERATOR a REGIONAL BOARD COMPANY OR AGENCY NAME <br /> p PRESLOCAL AGENCY OTHERto(L <br /> (L <br /> Q sADDRESS aoo9 -f,� � C6 q5.? o � <br /> STREET CITU STATE ZIP <br /> w NAME CONTACT PERSON PHONE <br /> co Q x-10 c Kdun. ,i 'e�S� j�,'sf UNKNOWN —7Qb )T`/q-`fb 7? <br /> w CL ADDRESS <br /> STREET CffV STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) -7OPERATOR PHONE <br /> -s u - C � b?o9)9vy-Y,!9 7e <br /> � ADDRESS <br /> STREET k <br /> COUNTY ZIP <br /> y CROSS STREET , n TYPE OF AREA 0 COMMERCIAL INDUSTRIAL�RURAL TYPE OF BUSINESS 0 RETAIL FUEL STATION <br /> �VQJ k (��. Ej]RESIDENTIAL F7OTHER a FARM ©OTHER <br /> LOCAL <br /> E ?#S _ L AGENCY NAeA CONTACT PERSON PHONE l <br /> w NCYL �l J\ , c `l Ste- b?o`�)�f6 9 3 dao <br /> w REGIONAL BOARD PHONE <br /> CL <br /> ( ) <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> U Q , UNKNOWN <br /> 5 (2) <br /> 0 UNKNOWN <br /> Z DATE DISCOVERED HOW DI VERED O INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> MM D O D y D yLZTANK TEST TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN UNKNOWN METHUSED TO STOP OD <br /> CONTENTS DISCHARGE(CHECK APPLY) <br /> REPLACE TANK0 CLOSE TANK <br /> w M M D D Y V <br /> HASDISCRGE BEENSTOPPED? REPAIRTANK REPAIRPIPING CHANGE PROCEDURE <br /> 0 NO IFYES,DATE M M DI DI Yl y OTHER <br /> w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL AUSE(S) <br /> TANK LEAK UNKNOWN / GAL. FIB GLASS OVERFILL RUPTURE/FAILURE <br /> crPIP GLEAK AGE J YRS STEEL CORROSION 0 UNKNOWN <br /> D OTHER UNKNOWN OTHER SPILL 5 OTHER <br /> W w CHECK ONE ONLY <br /> a UNDETERMINED SOIL ONLY E] GROUNDWATER a DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN FFECTED) <br /> F CHECK ON'ONLY <br /> zN <br /> cuj <br /> r a F SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS a SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> Tt F <br /> U y a NO ACTION TAKEN 0 POST CLEANUP MONITORING IN PROGRESS NO FUNDS AVAILABLE TO PROCEED E] EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> z ❑ CAP SITE(CD) F-] EXCAVATE&DISPOSE(ED) F7 REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) �CAVATE&TREAT(ET) PUMP B TREAT GROUNDWATER(GT) [�] REPLACE SUPPLY(RS) <br /> Cc TREATMENT AT HOOKUP(HU) NO ACTION REQUIRED(NA) OTHER(OT) <br /> DDDTa� � a�wN��� fayl, �� �SJoec-/iOy� <br /> z <br /> 6 <br /> HSC 05("7) <br />