Laserfiche WebLink
9115 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES 'FOR LOCAL AGENCY USE ONLY <br /> [] <br /> YES �D REPORT BEEN FILED 7 YES 1 HEREBY.CERTIF.YTHAT)HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> NO <br /> D! IBUTION HOWN ON HE NSTRU TON SHEET.ON THE BACK PAFORM. <br /> THIS FORM <br /> REPORT DATECASE e t { <br /> - <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> w REPRESENTING OWNERIOPERATOR REGIONAL BOARD COY OR AGENCY NAME <br /> ���m LOCALAGENCY OTHERrt <br /> ¢ ADDR144 ESS /� • ��JJ.,'}� �`{ <br /> , S02!me�:�^1 � (J `� CITY TE <br /> J �ZIP <br /> Lo ME Lor CghqACTPERSON rPHON�EJ f�7 y <br /> y �/l 54k O UNKNOWN 4I L7r )?7f 4 7 4 <br /> z¢ <br /> ADORESS <br /> COLa <br /> LE <br /> STREET ITY STATE ZIP �] <br /> O FNILITY NAME(IF APPLICABLE) � RATQR PHONE <br /> Ci It�Jff]i�w�A <br /> Q ADDRESS -eSt <br /> c � d <br /> w �er7 c cou ZIP p <br /> Do <br /> y CRO55 STREE7 [\��► <br /> 0 LOCAL AGE (Y`� AGENCY NAME TACT PE ON PHONE cc <br /> w U <br /> w w <br /> REGIONAL BOARD PHONE <br /> m (i) NAME QUANTITY LOST(GALLONS) <br /> LU O <br /> az w Q <br /> J UNKNOWN <br /> w p <br /> m� (2) <br /> UNKNOWN <br /> z <br /> z DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> Lu b r r TANK TEST TANK REMOVAL ❑ OTHER <br /> � ✓ u� o o <br /> m <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> .1 01 DI Yl Yl <br /> UNKNOWN REMOVE CONTENTS CLOSE TANK&REMOVE Lj REPAIR PIPING <br /> P HAS DISCHARGE BEEN STOPPED 7 E::]REPAIR TANK E�:]CLOSE TANK&FILL IN PLACE E::]CHANGE PROCEDURE <br /> YES [:] NO IF YES,DATE 6 M -LUI p Y 1 Y Q REPLACE TANK E] OTHER <br /> Lu SOURCE OF DISCHARGE CAUSE(S) <br /> aO TANK LEAK UNKNOWN pVERFILL pz RUPTURElFAILURE 11SPILL <br /> cn V PIPING LEAK OTHER CORROSION UNKNOWN OTHER <br /> w a CHECK ONE ONLY <br /> UNDETERMINED SOIL ONLY GROUNDWATER [:] DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERI7JITION <br /> crw <br /> r LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> O m F-1 REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) E::] CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> 16� oEius7 <br /> EXCAVATE&DISPOSE(ED) FL--] REMOVE FREE PRODUCT(FP) E] ENHANCED BIO DEGRADATION(IT) <br /> � BACK FaR <br /> o CAP SITE(CD) Q EXCAVATE&TREAT(ET) 0 PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> w a CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> 2 <br /> VACUUM EXTRACT(VE) OTHER(OT) <br /> 0 <br /> � � a., � � <br />