Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGE HAS STATE OFFICE OF EMERGENCY SERVICES fQR LOCAL AGENCY USE QNLY <br /> Q YES NO REPORT BEEN FILED 7 `� YES ❑ No 1HEAEBV CER71F�'THAT I NAVE DI5TR-TOUTED THIS INFORMATION ACCORDING TOTHE <br /> �7 "M IBUTION SHOW_N ON THE INST"&QN SHEECONr.T1iE BACK PAGE OF THIS FORM <br /> REPO RT DATE CASE x <br /> ml C-1 sICIIED <br /> ,DATE: :. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGMA <br /> Lo REPRESENTING � OWNERIOPERATOR Q REGIONALBOARD COMP.ANYORAGENCY NAME <br /> LOCAL AGENCY Q OTHER <br /> ¢ ADDRESS VCcZ jG rL���V IA 9 i Z C7 <br /> 3 0 LA 1 vs E4�—fL <br /> STREET CRY STATE ZIP <br /> NAME CONTACTPERSONPHONE <br /> � <br /> z �J�-� .J Q ��V UNKNOWN W 4 c i-tF( (YR MLT T--�G <br /> DRESS <br /> w ADI ZA--O L-oc� Rom er CA 9cc <br /> STREET CRY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR rPHONE <br /> 6 <br /> o AD r z�f o c � PaL � s�►.� 3o��v�t� 9 5z3 <br /> W STREET -t CRY COUNTY ZIP <br /> to CROSS'ISTREET <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> UO <br /> S�S Cb Ply S �o `_ (-�c:�.�-� 1��,.a-Q-� tyo5?�6�-3 V(/Z <br /> w REGIONAL BOARD PHONE <br /> W {1) NAME QUANTITY LOST(GALLONS) <br /> 0 <br /> Z>5 ��-�N� UNKNOWN <br /> z tzs <br /> UNKNOWN r <br /> Z DATE DISCOVERED /� HOW DISCOVERED 'Sr� INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> Lu w `.{,l! C3 M L_ In 0 '!r r 0 TANK TEST TANK REMOVAL OTHER L <br /> � �J l <br /> m DATE DISCHARGE BEGAN `Y-. ' METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> M ws o - o r r LY J UNKNOWN REMOVECONTEN3S CLOSE TANK&REMOVE Q REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> U <br /> o D YES 0 NO IF YES,DATE MoIII v Y REPLACE TANK OTHER <br /> -SQURCE OF DISCHARGE CAUSE(S) <br /> ca TANK LEAK UNKNOWN 0 OVERFILL 0 RUPTUREIFAILURE SPILL <br /> U 0 PIPING LEAK E] OTHER E::] CORROSION UNKNOWN OTHER <br /> w w CHECK ONE ONLY <br /> 0 a <br /> U UNDETERMINED SOIL ONLY GROUNDWATER ❑ 'DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY . <br /> z NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED Q POLLUTION CHARACTERIZATION <br /> Lu <br /> cc <br /> cc co BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ,POST CLEANUP MONITORING IN PROGRESS <br /> U y� REMEDIATION PLAN CASE CLOSED{CLEANUP COMPLETED OR UNNECESSARY) Q <br /> CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT)J (�b fail PEfA{,g( <br /> a z <br /> E5 Q CAP SITE(CD) Q EXCAVATE A TREAT(ET) Q PUMPS TREAT GROUNDWATER(GT)Q REPLACE SUPPLY{RS) <br /> a CONTAINMENT BARRIER(CB) NO ACTK)N REOUIRED(NA) TREATMENT AT HOOKUP(HU) E] VENT SOIL(V j) <br /> 0 VACUUM EXTRACT(VE) OTHER(OT) <br /> � So- ��, � �k�� c'�`� ✓� ,�� <br /> U <br /> HSC G5(WO) <br />