Laserfiche WebLink
Oc �0 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> 0 YES JjZ NO YES NO <br /> REPORT BEEN FILED? 1 HEREBY CERTIFYTHAT i HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. <br /> REPORT DATE CASE <br /> © M M © 1 O YI MNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGN3X6 9 <br /> E <br /> REPRESENTING a OWNEFVOPERATOR a REGIONAL BOARD COMPANY OR AGENCY NAME <br /> ¢ LOCAL AGENCY a OTHER l'oR(�Vivj Cvurl <br /> CC ADDRESSi/� //rJ //�\ C �y/ /� � (//�_�jw'� <br /> 3 " . el3 e ` 1�1 CRV tJ i�'�(J�/ STATE �/• \ 21P Z <br /> V STREET <br /> w NAME L �) CONTACT PERSON p� PHONE (// <br /> Z� ��� \ �I`�t� � 1" OUNKNOWN �rl� (GL��) 7L�2-�� <br /> cr <br /> a< ADDRESS `l.�/ /\/1 (-/I/� <br /> Lu �� \ STREET / ` ' , 1� �D clrY <br /> ��'D� STATE v A P 1 5� <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> GNB of-I-ti, 1� Svc p 11 � (Zee() ydZ-762 <br /> ~ <br /> a ADDRESS <br /> UL /� cm �(J �o v cou.TY <br /> O ZZ STREET M��"I�YJ �D <br /> w <br /> ~v CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CON T PERSON PHONE <br /> Lu U <br /> w wi. <br /> REGIONAL BOARD PHONE <br /> a <br /> NAME t ' QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> Z <br /> Q J /� <br /> H <br /> m 91 <br /> U)z (2) <br /> 0 UNKNOWN {\) <br /> U) <br /> z DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL O SUBSURFACE MONITORING a NUISANCE CONDITIONS <br /> c' (^/ 2 DI Y TANK TEST TANK REMOVAL OTHER 1 J`eM DU A( <br /> W v MI MI �D � o �Y O <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Q fx <br /> UNKNOWN REMOVE CONTENTS CLOSE TANK b REMOVE a REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED? Y REPAIR TANK CLOSE TANK d FILL IN PLACE CHANGE PROCEDURE <br /> V) 1 REPLACE TANK a OTHER <br /> o YES a NO IF YES,DATE M uI o(0 v Y <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> j a TANK LEAK 0 UNKNOWN E-1OVERFILL <br /> �E l RUPTURE/FAILURE a SPILL <br /> (h v )f PIPING LEAK O OTHER O CORROSION (X I UNKNOWN a OTHER <br /> LU w CHECK ONE ONLY <br /> Tn a- <br /> < UNDETERMINED <br /> vUNDETERMINED 0 SOIL ONLY GROUNDWATER [�] DRINKING WATER •(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFEC I ) <br /> CHECK ONE ONLY <br /> w NO ACTION TAKEN O PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED O POLLUTION CHARACTERIZATION <br /> a LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY a POST CLEANUP MONITORING IN PROGRESS <br /> v O REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) a CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) a EXCAVATE b DISPOSE(ED) <br /> REMOVE FREE PRODUCT(FP) 0 ENHANCED BIO DEGRADATION(IT) <br /> (SEE 8•-X r OETA l <br /> a z O CAP SITE(CD) F--j EXCAVATE d TREAT(ET) F7 PUMP 6 TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> Ow O NO ACTK)N REQUIRED(NA) TREATMENT AT HOOKUPU) a VENT SOIL(VS) <br /> w a CONTAINMENT BARRIER(CB) ( D ❑ <br /> ¢ VACUUM EXTRACT(VE) JL-KL OTHER(OT) <br /> rn <br /> z <br /> z <br /> w <br /> �o <br /> U <br /> HSC 05 W90) <br />