Laserfiche WebLink
4 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVIC FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED 7 <br /> ❑ res NO ❑ YES NO IHER BYCERTIFYTHATI HAVE DISTRIBUTED THIS INFORMATIONACCORDING TO THE <br /> REPORTDATECASE# DIS IBUT�N HE IN7rRUQTION SHEET BACK PAGE OF THIS FORM. <br /> 2 (/� 9 <br /> ( /J SIGNED DATE <br /> NF/ <br /> NAM OF INDIVIDUAL FILING REPORT <br /> m l�/1�19 PHONE GNA E <br /> w REPRES NG ❑ OWNERIOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> ¢ LOCAL AGENCY ❑ OTHER <br /> ADDRESS /,��J)�L,�(�////// <br /> /✓%tel E/� STATE <br /> w NA CON ACT PERSON <br /> m /��❑ PHONE <br /> U5 UNKNOWN �� �m �57 <br /> O< ADDRESS )^ <br /> Q 23?3 STREET %/ (/�(,� Cm �✓ STATE <br /> FACILI NAME(IF APPLICAB OPERATOR PHONE !!// <br /> ADDRESS l <br /> �- J <br /> 0 <br /> y CROSS STREET sTneEr couNrr v nP �J <br /> d 5 <br /> 0 LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> Nvr✓ �. P�{s ��� /NF��.Sz 6 s <br /> z w <br /> w= <br /> w REGIONAL BOARD / PHONE <br /> m (�) NAME QUANTITY LOST(GALLONS) <br /> 3� �E <br /> Z /Z0 <br /> w <br /> F UNKNOWN <br /> m i (2) � �! <br /> Eiff UNKNOWN <br /> z GATE DISCOVERED 99 HOW DISCOVERED E] INVENTORY CONTROL ❑ SUBSURFACE MONITORING - �NUISAN-CE/CONDITIONS , <br /> /M1 0.1 `n So� ( r /r ❑ TANK TEST ❑ TANK REMOVAL OTHER Otlr ❑ <br /> QDATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) 1. <br /> M .1 DI 01 y Y UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK O CLOSE TANK d FILL IN PLACE ❑CHANGE PROCEDURE \n <br /> o BYES ❑ D NO IF YES,DATE aM bMI ODo 8,17-, F-]REPLACE TANK ❑ OTHER _ 1 <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> a ❑ TANK.LEAK EZIUNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE E ❑ SPILL <br /> w0 ❑ PIPING LEAK ❑ OTHEfl ❑ CORROSION UNKNOWN ❑ OTHER <br /> ww CHECK ONE ONLY <br /> O ❑ UNDETERMINEDFfIZIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> O NO ACTION TAKEN ❑ EUMINARYSITE ASSESSMENT WORKPLAN SUBMITTED E:] POLLUTION CHARACTERIZATION <br /> a ❑ <br /> �y LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) O EXCAVATE&DISPOSE(ED) O REMOVE FREE PRODUCT(FP) O ENHANCED BIO DEGRADATION(IT) <br /> (SEE B,LR WIOEfN51 <br /> QZ <br /> 00 CAP SITE(CD) ❑ EXCAVATE B TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY IRS) <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) F--] OTHER(OT) <br /> Rsc a <br />