Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTH E IJASE(L AK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGF.N USE ONLY <br /> REPORT BEEN FILED 7 <br /> YES NO [] YES NO )fiEREBYCERT3FYTHAC( fAVEDISTRIBIf[EDTFfISIhEaRMATIONACCOR>)IMGTOTHE: <br /> "I IBUT1 SH01N THE STRU !ON Si{EET,ON BACK PAGE OF: FOA <br /> REPORT DATE CASE s <br /> 5r S1GiEFD..:.. . <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGN RE <br /> /tic & i&� <br /> w REPRESENTING OWNERIOPERATOR Q REGIONAL BOARD COMPANY OR AGENCY NAMEE/��, <br /> SLOCAL AGENCY OTHER <br /> ADDRESS <br /> �3 �' c� S �/ ATI �— 93 ,E <br /> w NAME! CONTACT PERSON PHONE <br /> z �� i Ci UNKNOWN <br /> t�,v��5 �izo �e ❑ leo Z j 9�31of1 i <br /> Na ADDRESS <br /> STREkT fyocSTATE <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> A. a , fZ� az"¢s 1-3 04 <br /> s ADDRESS` ��� /� f 7(/ <br /> La �O/ STREET g i i^�L4 � CfYY / C UNTY pI_N/Z <br /> y CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> u,W O/nIB S .W� � � i� c�v>¢ (Zo9)5ll��ySo <br /> M REGIONAL BOARD PHONE <br /> ew Lc -bc L 3u�G s t�j/d)ZrJ5313 9 <br /> (t1 f / /�NA�M}E� QUANTITY LOST(GALLONS) <br /> LU <br /> O �O D &((/ [ G7�'IT�o 1-,./ UNKNOWN <br /> Zw <br /> �p <br /> m 2 <br /> N UNKNOWN <br /> z DATE DISfCOVERED g HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> ai W ` M uI Vo / rI�r ❑ TANK TEST TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a <br /> w u o v r <br /> UNKNOWN [—]REMOVE CONTENTS [:]CLOSE TANKS REMOVE REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 REPAIR TANK CLOSE TANK&FILL IN PLACE CHANGE PROCEDURE <br /> U <br /> a Q YES N6 IF YES,DATE MI Y Y REPLACE TANK Q OTHER <br /> SOURCE OF DISCHARGE CAUSES) <br /> w <br /> c ❑ TANK LEAKNKNOWN OVERFILL RUPTUREIFAILURE 0 SPILL <br /> y U E-1 PIPING LEAK F1 OTHER CORROSION UNKNOWN Q OTHER <br /> H wa CHECKONEONLY4 a <br /> U ❑ UNDETERMINED SOIL ONLY GROUNDWATER DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> i <br /> CHECK ONE ONLY <br /> Lu <br /> NO ACTION TAKEN �Q�(' PREEIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED Q POLLUTION CHARACTERIZATION <br /> cr <br /> w a LEAK BEING CONFIRMED 17GI PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS' F <br /> v w Q REMEDIATION PLAN F-1 CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY ) <br /> I <br /> CHECK APPROPRIATE ACTION(S) 71EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(m <br /> ISM a cx FCA Oct" <br /> wp CAP SITE(CD) EXCAVATE d TREAT(ET) PUMP&TREAT GROUNDWATER(GT) ,REPLACE SUPPLY(RS) <br /> w Q CONTAINMENT BARRIER(CB) NO ACTION REOUIRED(NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> s <br /> ❑ VACUUM EXTRACT(VE) Q OTHER(O") <br /> /e.�7L /Ntf�srl fryga-ra,✓ 2�ur��7� d y �� Overs���r ���jp <br /> LLJ <br /> Q/�L�Lnci.�� ��—�+�7` � .cJ�'z��E✓ a7� �.�/T����.�7d�J. sc.r� <br /> Hse os(aso, <br />