Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT - <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> REPORT BEEN FILED ? FOR LOCAL, AGENCY USE ONLY. ` <br /> ❑ YES ElNO ❑ YES NO I HEREBY CERTIFYTHAT i HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO TH <br /> DIS IBUTION SHOWN ON THE INSTRUCTION SHEET-ON THE BACK PAGE OFTHIS FO M <br /> REPORT DATE CASE * <br /> M / M 9 V S N DA IBJ <br /> DATE : <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> Qre L • unfe r ( 9u ) BY2- 95 a .Z°' /✓ <br /> REPRESENTING OWNERIOPERATOR ❑ REGIONAL BOARD COMPANYOR AGENCYNAME <br /> o ❑ LOCALAGENCY ❑ OTHER <br /> C �( evron Pr42,bC711 CA2m <br /> ADDRESS <br /> /�• 0 . /3oX (oODA San Rargon, Cff 9HSS3 -D9vy <br /> STREET CITY STATE ISP <br /> w NAME /� �/ CONTACT PERSON PHONE <br /> y � <br /> CA evrcn Prvilvtis ` OM41OA/ ❑ UNKNOWN Rre, 7f" /fun fi r ( 925) OAIIW G95 <br /> Oa a ADDRESS <br /> /�, D • Flvx l00�/ San RamVr7, CR 9'ef83 - D90y <br /> ST <br /> REEF c" STATE zip <br /> FACILITY NAME (IF APPLICABLE) OPERATOR PHONE <br /> o CArvron Servue C+a { ian 9 -3232 Ci1eVrQn Prod D9y7 <br /> o ADDRESS $ � �D /wwer Sacrarnenfo 2d• S{-acKton San J04 Ven g5Aj0 <br /> 0 <br /> c REST CITY coux ZIP <br /> h CROSS STREET <br /> Ponce AeLean <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> San Joag � (n Covn+y Pt} S — EI} p I-} arlln Knoll ( zo9 ) yb �b 3y <br /> ww REGIONAL BOARD <br /> O PHONE <br /> Cen ra l Valley RwacA3 Mar x /,) S ( 91 to ) 255 30} I <br /> w NAME QUANTITY LOST (GALLONS) <br /> � w UNKNOWN <br /> y o> fz) <br /> ❑ UNKNOWN <br /> DATEDISCOVEREDDISCOVERED HOW DISCOVERED E] INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUIS1ANCE CONDITIONS <br /> / W M DI / 0 9 YJ S Y ❑ TANK TEST ❑ TANK REMOVAL OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br /> a <br /> UNKNOWN ❑ <br /> M Y YREMOVECONTENTS IXLCLOSETANK & REMOVE REPAIR PIPING <br /> c <br /> HAE-S-,D(ISCHARGE BEEN STOPPED ? �❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE ❑ CHANGE PROCEDURE <br /> VES ❑ NO IF YES, DATE OM BM I o 5 o Y V tgREPLACE TANK ❑ OTHER <br /> � w SOURCE OF DISCHARGE CAUSE(S) <br /> j ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> 00 ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w CHECKONEONLY <br /> O Z ❑ UNDETERMINED ❑ SOILONLY GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w Z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ❑ LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U M <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <br /> aZ <br /> ❑ CAP SITE (CD) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) REPLACE SUPPLY IRS) <br /> wZ <br /> wa ❑ CONTAINMENT BARRIER (CS) ❑ NO ACTION REQUIRED INA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br /> ❑ VACUUM EXTRACT (VE) �. OTHER (OT) llvriAer s I pll[ m rG <br /> /� � �lal r� /r assrss.� tnf neap ca. ploHan . Fu� tkt � sifc arsrssnrnl �rooniFanny <br /> s uarranfra� . Coerrcll ✓c action /aAtl7lycraxohili // s /ualy /a be /aPr`ormed <br /> 8 once exkr �- of ronigomInt? bon &Wetinee(• <br /> HSC 0 (maul <br />