UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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q �- u OC9 UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY F-1 YES �NO REPORT BEEN FILED 9 YES F NO 1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM REPORT DATE CASES ►7 : M MI / v -SGNED - DAT NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATU w REPRESE TING E-] OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NA pLOCAL AGENCY ❑ OTHER b •� V/� ¢ ADDRESS ? STREET CfTY STATE ZIP�IA/ w NAME CONTACT PERSON PHONE J z 2 F�� E Q UNKNOWN L_#�l ) '��ZZ. no as ADDRESS U)w ¢ STREET CRY '54 i STATE CA- g�, .J FACILITY NAME(IF APPLICABLE) OPERATOR PHONE U ADDRESS O I w STREET 1 CRY AnJ COUNTY ZIP / 7 6 CROSS STREET tk)�,- 4 - LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE z Z W w U w w REGIONAL BOARD PHONE 0 IL IL a ( ) (n (t) NAME QUANTITY LOST(GALLONS) , LU O U w UNKNOWN Z a J E- 20 (2) D U) O UNKNOWN z DATE DISCOVERED /I HOW DISCOVERED ❑ INVENTORY CONTROL ❑ UBSURFACE MONITORING ❑ NUISANCE CONDITIONS w SMI MI DI b DI cl vI v ❑Lu TANK TEST ❑ HER TANK REMOVAL OT a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARG (CHEC ALL THAT APPLY) m a ❑CLOSE TANK 8 REMOVE ❑REPAIR PIPING UNKNOWN ❑REMOVE CONTENTS Lu M M D D Y Y 1 Eia� p HAS DISCHARGE BEEN STOPPED 4 ❑REPAIR TANK ❑CLOSE TANK 8 FILL IN PLACE E:]CHANGE PROCEDURE o ErYES a NO IF YES.DATE I ml IMI D v Y E:]REPLACE TANK Fo OTHER 4 D 12EPlAerzd L ,02Z> SOURCE OF DISCHARGE CAUSE(S) Ca ❑ TANK LEAK E2-UNKNOWN ❑ OVERFILL �E�:] RTURE/FAILURE ❑ SPILL 1)�� ❑ PIPING LEAK © OTHER ❑ CORROSION NOWN ❑ OTHER w w CHECK O ONLY �a v UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER •(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION N ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS v ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE E DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) J (SEE BACK FOR MAKS) Z ❑O CAP SITE(CD) F-] EXCAVATE&TREAT(ET) ❑ PUMP 8 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) w w� Lu a ❑ CONTAINMENT BARRIER(CB) E:] NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) ¢ ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) co z 5� r\A�j �`�� f�7r-�►.rl-' O-� Co r�-�t.1+ i t..io�-�-�o►�l LuO U HSC 05(MO)