Laserfiche WebLink
C/ -� <br /> - c,Iy <br /> -� <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> YES O NO REPORT BEEN FILED? YES ��/ I>HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> �/J "A' REPORTED THIS INFORMATION TO LOC OFFICIALS PUR DANT TO SECTION 25180.7 OF <br /> REPORT DATE CASE i THE HEALTH 0 SAFTY CODE <br /> 0. �M o 7D (v 3v SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE A <br /> m eQ/'l©-,' c, )y g 033 Y <br /> REPRESENTING 0 OWNER/OPERATOR O REGIONAL BOARD COMPANY OR AGENCY NAME <br /> LOCAL AGENCY OTHER .__." C (f J <br /> w <br /> ADDRESS <br /> L STREET ;r? <br /> STATE ZIP <br /> Lq NAME 9 CONTACT PERSON PHO/NEE <br /> ZV UNKNOWNcr C ��t✓ n t/ (2`�/1 ( / / / <br /> Ra ADDRESS <br /> K <br /> yA /fJ /{� �5Zc�3 <br /> CL 3 Z STREET V l` CfTY ✓ �C�/4i STATE` ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS Z .f44EET to cm 5�cl fv,-7 24,5 <br /> G� <br /> / ZIP <br /> a-i CROSS STREET TYPE OF AREA [:]COMMERCIAL [:]INDUSTRIAL 0 RURAL TYPE OF BUSINESS 0 RETAIL FUEL STATION <br /> a RESIDENTIAL O OTHER FARM O OTHER <br /> LOCAL AGENCOF AGENCY NAME CONTACT PERSON PHONE <br /> LU <br /> , REGI NAL BOARD PHONE <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> N <br /> 05-t UNKNOWN <br /> J <br /> U) F-1 UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED 0 INVENTORY CONTROL 0 SUBSURF E MONI ORING F.;- ANCE CONDITIONS <br /> 2 ciM � TANK TEST a TANK REMOVAL OTHER _ C o' <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> M M D D Y Y <br /> > HAS DISCHARGE BEEN STOPPED? REPAIR TANK REPAIR PIPING CHANGE PROCEDURE <br /> -p D YES 0 NO IF YES,DATE M 71 20 !' v 3v OTHER <br /> Lu SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> TANK LEAK [:] UNKNOWN Z� r2� ) GAL. O FIBERGLASS OVERFILL RUPTURE/FAILURE <br /> PIPING LEAK AGE YRSEEL CORROSIONNK OWN <br /> 2 [::] OTHER UNKNOWN OTHER SPILL [::] OTHER <br /> W w CHECK ONE O Y <br /> UNDETERMINED SOILONLY GROUNDWATER DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> zcn <br /> E] SIT VESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS 0 SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U N NO ACTION TAKEN 0 POST CLEANUP MONITORING IN PROGRESS O NO FUNDS AVAILABLE TO PROCEED [:] EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> z F--] CAP SITE(CD) F--] EXCAVATE 8 DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> 00 <br /> Lu Lu 0 CONTAINMENT BARRIER(CB) EXCAVATE&TREAT(ET) PUMP 8 TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> TREATMENT AT HOOKUP(HU) NO ACTI��ON�t REQUIRED(NA) 0 OTHER(OT) <br /> G 4 o-i t.✓1`t� [, lgvi e -)io <br /> w <br /> HSC 05(11-7) <br />