Laserfiche WebLink
q 3- Us <br /> 1 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY;;Z� <br /> FOR�.QCAC AGENCY:USE.ONLY <br /> REPORT BEEN FILED? IHEREBYC€RnF.YTHATi)iAVEDISTRlBUTEDTArSINFORMAT)ONADCDRDINGTpTHE <br /> YES NO YES <br /> DISTRIBUTldN SFIpWPCON gdSTRU EE r. THE BACK P <br /> AGE OF THIS FARM <br /> REPORTOATE © � CASES <br /> M M v <br /> .... <br /> NAME OF INDIVIDUAL FILIIV EPORT PHO SIGNATURE _ <br /> m rro/ i �r � ba ;033 <br /> Lu REPRESEN OWNER/OPERATOR ❑ REGIONAL BOAROJ COMPANY OR AGENCY NAME <br /> cc LOCAL AGENCY OTHER <br /> ,i 4-1 <br /> ADDRESS /�f )�+- <br /> 4L4 S, • STREET �Q �I`�I CITY ✓ �I STATE �Sp <br /> Iy NAME _ CONTACT PERSON PHONE <br /> z �f C) (vCIQ 4UNKNOWN <br /> a Qa ADDRESS <br /> P. p 7 <br /> Ox � S r <br /> P. <br /> bLu <br /> o �srR DEET a rl e> Carr s /ei I?C v srATE C-4 pA� <br /> FACILITY NAME(IF APPLICABLE) l OPERATOR PHONE <br /> g .L� 4 Uca v t� Joe v-,e6nA l ) <br /> UADDRESS is c- <br /> � LILSTREET L 4 i �+�� cm � f'C7 couNry p <br /> 0 CROSS STREET <br /> r,l LI �V�n t <br /> O LOCAL AGENCY AGENCY NAME CONTACT PEASON PHONE <br /> 5—f— <br /> W Sc.n a � A 1-�' �;-� I?. ) Cdr 033 <br /> w w REGIONAL BOARD PHONE <br /> cz S . f�6 ) LS S—3 C <br /> y (1) NAME L I QUANTITY LOST(GALLONS) <br /> Lu Q <br /> ¢LLI NKNOWN <br /> m_z <br /> y� <br /> s ( ❑ UNKNOWN <br /> DATEI DI,SrC�OVEREED,' HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING C:] NUISANCE CONDITIONS <br /> 2..l �o r Lu 3v ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> aDATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> 4 <br /> NKNOW <br /> I A <br /> w u u o r <br /> N E:]REMOVE CONTENTS OSE TANK s REMOVE ❑REPAIR PIPING <br /> cc HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> `n <br /> ES [—] NO IF YES DATE M o r yl <br /> ❑REP(LACE TANK E::]OTHER <br /> O SOURCE OF DISCHARGE CAUSE(S) <br /> jc ❑ TANK LEAK NKNOWN ❑ OVERFILL E::] RUPTUREIFAILURE ❑ SPILL <br /> w L) ❑ PIPING LEAK ❑ OTHER CORROSION NKNOWN OTHER <br /> H a CHECKON NLY <br /> v UNDETERMINED ❑ SOIL ONLY GROUNDWATER [7] DRINKING WATER -(CHrzcK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> i NO ACTION TAKEN INARY SITE ASSESSMENT WORKPLAN(SUBMITTED POLLUTION CHARACTERIZATION <br /> w <br /> cr <br /> LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY( POST CLEANUP MONITORING IN PROGRESS <br /> o ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) F--1EXCAVATE 3 DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED 810 DEGRADATION(LT) <br /> (SEE ellX TCR OEM$) <br /> Q o ❑ CAP SITE(CD) ❑ EXCAVATE 5 TREAT(ET) ❑ PUMP b TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> wti <br /> sa ❑ CONTAINMENT BARRIER(CS) NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> UUM EXTRACT(VE) ❑ OTHER(OT) <br /> ui <br /> 0 <br /> U <br /> IiSC OS{flR0! <br />