Laserfiche WebLink
V `7 b <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> REPORT BEEN FILED FORLOCAL'AGENCY USE ONLY <br /> 7 <br /> YES [] NO [] YES [] NO1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTEO THIS INFORMATION ACCO R01NGTO THE <br /> DISTRIBUTION SHOWN ON THE INSTR TION SHEET ON THE BACK PAGE OF THIS FORM; = <br /> REPORT CATS CASE# <br /> f <br /> al 6.1 "` <br /> SIGNED. GATE , <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> Irl <br /> m <br /> REPRESENTING ❑ COMPANYOR AGENCY NAME <br /> OWNERIOPERATOR REGI NALBOARD <br /> O iK1 LOCALAGENCY ❑ OTHER <br /> ow[ ADORES �!/gy ��ff�/f/J� {///� 7 r {/� \J <br /> f X S'fR ! Cli�' 0 1 STATE <br /> J NAME -/ ' ,UN_+ NNP <br /> HONE <br /> z� UNKNOWN � ry <br /> O <br /> ' <br /> CL 4a ADDRESS <br /> a• <br /> /j /�/[ <br /> w l V f 'bT� Y CITY /(� ���/' - STATE <br /> FACILITY NAME(IF APPLICABLE) ., OPERATOR PHONE <br /> o4re Ab <br /> ( ) <br /> q ADDRESS <br /> O �. <br /> H 'v V ✓3TRET V ! 1. -� cITY COUNTY zIP�J <br /> m CROSS STREET <br /> (7 LOCA!AGENCY AGENCY NAME CONTACTPERSON PHONE. <br /> w <br /> w� . <br /> LL, <br /> REGIONAL BOARD <br /> a VL°lf7 C/ PHONE <br /> y (1y NAME QUANTITY LOST(GALLONS) <br /> wC3 <br /> Wit a le t pv, dire c6P.b'U UNKNOWN <br /> r <br /> m z (�) <br /> 0z <br /> UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING E] NUISANCE CONDITIONS k <br /> Fws�! I�� / Ooi r r ❑ TANK TEST TANK REMOVAL ❑ OTHER f F <br /> o DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) �(Y� <br /> w mi u p b r r UNKNOWN <br /> REMOVE CONTENTS <br /> CLOSE TANK 8 REMOVE ❑REPAIR PIPING ` <br /> } HAS DISCHARGE BEEN STOPPED T ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> O <br /> Es ❑ YES ❑ NO IF YES,DATE MI uI DiI Y1 Y ❑REPLACE.TANK ❑ OTHER <br /> SOURCE OF DISCHARGE. CAUSE(S) <br /> a ❑ TANK LEAK ( UNKNOWN ❑ OVERFILLLlRUPTUREIFAILURE ❑ SPILL <br /> cn O ❑ PIPING LEAK ��� OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> Lu w CHECK ONE ONLY <br /> L) UNDETERMINED' ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WAFER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY ) <br /> z ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY 1 <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED B10 DEGRADATION(IT) <br /> a z fWE BACK FOK DET ) <br /> a o ❑ CAP SI;E(CD) ❑ EXCAVATE 8 TREAT(E7) PUMP&TREAT GROUNDWATER(GTI❑ REPLACE SUPPLY(RS) <br /> w i= p <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) F <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> LJ <br /> h2 u r'a� �2-f�2 rpie -fie yr _ 6 <br /> Crs nuc s� �'�l <br /> A-5 !/ 6 AreGG r'O i'��,' <br /> y� � ,�• � �y /!�Gf / v HSG n518r9Vj <br /> 4 fJ�-cf] 7 J <br />