Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALAGENCYUSE ONLY <br /> REPORT BEEN FILED 7 ::HEREBY CERTIFY THAT t AM AZ II.ONATED GOVEANMEN7 EMPLOYEE AND THAT i HAVE <br /> ED YES NO ❑YES EDNO AEPORTED:THIS tNFORMATION TO LOCAE.OF ICIALS PURSUANT T, SECTION 25;80:7 OF <br /> THE HEALTH AND SAFTY CODE <br /> REPORTDATECASES t r CC <br /> t�Jryl fJj SIGNED 77 <br /> E <br /> M M =REPORT <br /> NAME OF INDIVIDUAL PHONE SIGNATURER PRESENTING� OWNER/pPERATOR ❑ GtONALBOARD �MPANYORAGENCYNAME <br /> ❑ u� 611(- I I.C� � <br /> lscr �Loc <br /> ❑ OTHER <br /> ADDRESS /� R �( ST ��`�J�/� <br /> F. v/ t V O /� STRE GTY `-a ock `� � STAT <br /> NAME 54doLvoL P1.5e'WNTACTPERSON PHONE <br /> y� <br /> NAwTa&A <br /> � ❑ UNKNOWN (j� sf' � Sz-�3� <br /> //// 3 <br /> d ADDRESS REET� Vv �5 CRY '/�� STATE � 47-'r7 <br /> �7P <br /> FACILITY NAME(IF APPLICABLE) / / 01S� OPERATOR (/I� /PHONE <br /> ViV i ( <br /> tj ADDRESS kve' 64 <br /> V I STREET ✓ Cm' COUNTY ZIP <br /> yCROSS STREET TYPE OF AREA ❑COM L❑INDUSTRIAL❑RURAL TYPE OF BUSINES3 ❑ RETAIL FUEL STATK)N <br /> p O ❑RESIDENTIAL ER ❑ FARM ❑ OTHER <br /> LOCALAGENCY /� AGEdC� IjdF� /*� CONTACTPERSON PHONE <br /> J .-.a�UU�/ (v0 W F-3� -�o <br /> W 1<. a N �JZ. �5 0 � <br /> 2 REGIONAL BOARD PHONE <br /> G ) 361 x'600 <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> (a ❑ UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> q TANK TEST ❑ TANK REMOVAL ❑ OTHER <br /> ►1 0 o Y 1 r <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> M D o r r <br /> HAS DISCHARGE BEEN STOPPED Z 0 REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> rX �N Mptl <br /> ❑ YES �N IF YES, OI o v v OTHER <br /> M M <br /> SOURCE OF DISCHARGE TANKS ONLY)CyAPACITY MATERIAL CAUSES) <br /> a TANK LEAK >51 UNKNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREiFALURE <br /> 0 PIPING LEAK AGE YRS STEEL ❑ CORROSION UNKNOWN <br /> Q OTHER cw <br /> UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> ` a+�ac oNLr <br /> 1' UNINTERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> Ow" ONLY <br /> ^` ]� "WOTIGATK)N IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> n 1. Q aD AOT1aN TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATNG CLEANUP ALTERNATNES <br /> CHOWWWMA11%AO f IONS)(SEE BACK FOR DETAILS) <br /> w am m ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 1310 DEGRADATION(IT) <br /> 0" kN T IlIA11RIER(CB) ❑ EXCAVATE 3 TREAT(ET) ❑ PU P& <br /> TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> +� "*NF A f 1 MKUp(HU) ❑ NO ACTION REQUIRED(NA) OTHER(OT) <br /> L rrec i s�e n yt a A,-4 <br /> �e ,�,�•�1e2 ,s�� assesSm��' w�GG/h`. !� u�� � <br /> Aima- <br /> As <br /> 411 by <br /> HSCOS(mm <br /> f <br />