Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> tREPORT <br /> ENCY HAS STATE OFFICE OF EMERG SEflVICES FOR LOCAL AGENCY USE ONLY <br /> S ND REPOfli BEEN FILED 7 YES Q NO I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE ANDTHAT THAVE <br /> REPORTED THIS INFORMATION TO LOCAL OFFX:ULLS-PURSUANT TO:SECTION 25140.7 OF <br /> i. DATE CASED - iHEHEAI AND <br /> VCODE - <br /> M �Na m� <br /> NAME OFINrDIVIOUAL FILING REBORTf PHONE SIGNAT RE DATE <br /> I_. flEPRESE G O OWNERIOPERATOR Q REGIONALBOARD COMPANY OR AGENCY NAME <br /> LOCAL AGENCY OTHER S,:4-P H S <br /> ¢ <br /> AEFS �oO <br /> NAME - spy COTACTPEi ON gAPHONE TE ZIP . <br /> °1 T I I/Qt/Ylt LPJL� L YvI T• 1 1 P <br /> yUNKNOWN <br /> ADDRESS <br /> TREE! <br /> FACILITY NAME IIF APPLICABLE) CRY VATE rP <br /> OPERATOR PHONE <br /> Q <br /> ADDRESS <br /> 9TREE <br /> y CROSS STREET TYPE OF AREAQCOMMERCIAL 0 WOUSTRIAL .RURAL TYPEOFSUSINESS <br /> ETAIL FUEL STATION <br /> do Q RESIDENTIAL Q OTHER Q FARM OTHER (n IQ,C(?d, ' <br /> LOCALAGENCY <br /> AGENCCQNTACTPERSON <br /> S NS <br /> � PHONE <br /> Envirov,m �YNAME <br /> iIs 4) <br /> wty REGIONAL BOARD PIgNE <br /> CuRkJ CQ I ) <br /> y Itl NAME <br /> QUANTITY LOST(GALLONS) <br /> 09 a fro lei ) C� <br /> d UNKNOWN <br /> (2) <br /> N <br /> O UNKNOWN <br /> W OATS DISCOVERED // J[(�,., HDW DISCOVERED O INVENTORY CONTROL 0 SU URFACE MONITORING O NUISANCE CONDITIONS <br /> w OM � o lip V Y Y 0 TANK TEST 2TTAW REMOVAL OTHER &0 1' �. <br /> m F DATE DISCHARGE BEGAN /� METHOD USED TO STOP DISCHARGE(CHECK ALL THA MPL <br /> w u u o o Y Y lYJ `"•^")OWN O REMOVE CONTENTS gEPLACE TANK OSE TANK <br /> Q HASDISC RGESEENSTOPPED9 D'] !� �yy [_jREPAIRTANK O REPAIRPIPWG CHANGE PROCEDURE <br /> o VES 0 NO IFYES.DATE �p �p L Y O OTHER <br /> H SOURCE OF DISCHARGE TANKS ONLYCAPACITY MATERIAL CAUSE(S) <br /> q Q TANKLEAK UNKNOWN GAL, FIBERGLASS Q OVERFILL E] RUPTUREFALLURE <br /> a El PIPINGLEAK AGE YRS 0 STEEL CORROSION E'UNKNOWN <br /> O OTHER UNKNOWN Q OTHER 0 SPILL 0 OTHER <br /> ywy w CHECK ON LV <br /> UNDETERMINED I] SOILONLV O GROUNDWATER 0 DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ON V <br /> Z y <br /> ¢a SITE.INVESTIGATK)N IN PROGRESS(DEFINING EXTENTOF PROBLEM) O CLEANUP IN PROGRESS Q SIGNEDOFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> V'A O NOACTioNTAKEN E:] POST CLEANUP MONITORING IN PROGRESSED NO FUNDS AVAILABLE TO PROCEED O EVALUATING CLEANUP ALTERNATIVES 'I <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> CAP SITE(CD) O EXCAVATE&DISPOSE(ED) O REMOVE FREE PRODUCT(FP) El ENHANCED BIO DEGRADATION(IT) <br /> O CONTAINMENT BARRIER(CB) EXCAVATE&TREAT(ET) O PUMP&TREAT GROUNDWATER(GT) O REPLACE SUPPLY IRS) <br /> O <br /> TREATMENT AT HOOKUP(HU) O NO ACTON REQUIRED INA) O OTHER(OT) <br /> /L.ri,•;� r '�' • S ezi, <br /> nscosi�a>t ' <br /> CG4 , <br />