Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY '. <br /> REPORT BEEN FILED T <br /> YES No � YES No 1HEREBY CERTiFYiNAT1 HAVE DISTRIBUTED THIS INFORMATION ACCORDING TOTHE <br /> REPORT DATE <br /> DISTRIBUTION SHOWN ON TRE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> CASES <br /> OM S'MI U 46 D SIGNED <br /> GATE <br /> NAME Of INDIVIDUAL FILING REPORT PHONE SIGNATU_ RE <br /> I��IQ� r,� t�vocc ) 5_3Vg2 <br /> w REPRESENTING O OWNER/OPERATOR O REGIONAL BOARD COMPANY OR AGENCY NAME C <br /> S <br /> LOCALAGENCY Q OTHER <br /> ADDRESS <br /> Soq E. [.�Er� /SEETR+1� SToc(Crn.. C� FrJoz <br /> C" STATE ilv <br /> w <br /> NAME L CONTACTPERSONN PHONE <br /> iQ ✓.F/lATL"iD T..n..C/ UNKNOWN <br /> a d <br /> ADDRESS <br /> �-14L' "- / <br /> STATE j,P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o (30jc-TD 011, CAtemL0i <br /> ADDRESS �7 O L� I(�.� �•A �. O C�.AJ f( (3(t/p/CO. IrL31 <br /> w o� z S. fete r2A • f/�C^ cm T`N P <br /> w CROSS STREET <br /> eoTt+ <br /> ° LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> _� St4N5o4cCiur,u co. E+t� L-6Q.eLr� lt,va� <br /> w w REGIONAL BOARD PHONE <br /> _` CUQU✓l,Zt,�j �6, S 'S►rY. t5�4te.�cDu ( ) b <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> w° <br /> Ell"UNKNOWN <br /> �O m <br /> m> <br /> N <br /> O UNKNOWN <br /> i DATE DISCOVERED HOW DISCOVERED O INVENTORY CONTROL SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> ' LM Z .10 Y Yl ❑ TANK TEST ❑ TANK REMOVAL O OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> w M p YJ AUNKNOWN REMOVE CONTENTS O CLOSE TANK B REMOVE REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 O REPAIR TANK O CLOSE TANK&FILL IN PUCE O CHANGE PROCEDURE <br /> o ❑ VES a NO IF YES.DATE M c V a REPLACE TANK Q OTHER <br /> � SOURCE OF DISCHARGE M CAUSE(S) <br /> ¢Q TANK LEAK UNKNOWN OVERFILLO RUPTURE/FAILURE SPILL <br /> �O O PIPING LEAK O OTHER O CORROSION UNKNOWN OTHER <br /> y w CHECK ONE ONLY <br /> ° UNDETERMINED SOIL ONLY K2 GROUNDWATER O DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wZ Eo NOACTIONTAKEN F-1PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED O POLLUTION CHARACTERIZATION <br /> jy ❑ LEAK BEING CONFIRMED a PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> ° ❑ REMEDIATION PLAN a CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) 0 CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTIONS) 0 EXCAVATE 6 DISPOSE(ED) REMOVE FREE PRODUCT(FP) O ENHANCED BIODEGRADATION(IT) <br /> 1�a..ca wn DETMHI <br /> a <br /> O 6 F-1CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) Q PUMP E TREAT GROUNDWATER(GT)Q REPLACE SUPPLY IRS) <br /> ❑ <br /> w <br /> w< � CONTAINMENT BARRIER(CR) NO ACTK)N REQUIRED(NA) E] TREATMENT AT HOOKUP(HU) Ej VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) OTHER(OT) <br /> Lr .Qnt.r-L cQetA-2-r�1c� F�t11H aaria.•t'n St�C Q-�-dR-Qd�+'U� IA/G-7a.�y�•,.t(�.�pd cZ <br /> ,QD4f UR�JL" MAZ /� Gl ofiC TtA/L -/J..� <br />