Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AG CY U <br /> YES [] HIO CE <br /> REPOR7BEENfLED7 VES ❑ NO R�EPOHTED F ION TpTE0 GOVERNMENT QfFICU1S PURSUANT TO SECTION 25160.AND THAT J 7AVE <br /> Of <br /> ' REPORT DATE � G CASE• THEHEAL q jfzl�, ti <br /> 4 <br /> Oa M 1 0- Y/ SI <br /> yO V GNED ATE 4 <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGMJITU <br /> 'DaAd 1 (2,--o, ) K3�ly� <br /> REPRESENTING ❑ OWNEROPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> p LOCAL AGENCY Q OTHER „ 30 ..i1 Loc.n l [7 C-q 1�. $ ✓rL- <br /> REss <br /> I(oaI F_� 4" l-=.- �px zaa931 <br /> ElmliCITY STATE zP <br /> NAME CONTACTPERSON PHONE <br /> PG ca��-at <br /> u�a ADDRESS ,ul p A P D Q E c � Ci s`3 L� <br /> S <br /> 2-0-o { k c-A rk%- S/,TREEC. IO TG Cm�o K STATE P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS CA <br /> STREET <br /> 20001 L�Q.nr P go,c `�S� �Tc�1o., C ' 1 <br /> STREET CITY COUNTY <br /> mCROSS STREET TYPE OF AREA ❑COMMERCIAL ❑INDUSTRIAL❑RURAL, TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> 0.1 S t ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> /�� 2(f S <br /> W ✓_' V�I r,1"� {.����4 CAi 1 \ �� ���✓4 1411�l �4�r1) 4(OC 1 l G <br /> w REGIONAL BOARD PHONE <br /> eL <br /> )3bc—Sc�� <br /> m (1) NAME OUANTfTY LOST(GALLONS) <br /> x �-f, UNKNOWN <br /> I2 ` <br /> UNKNOWN <br /> GATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> W ❑ ❑ ❑ <br /> CJ u u p 6 p �v v ❑ TANK TEST Ro TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> N w o 01 yl yl UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK � CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED? GG E] REPAIR TANK ElREPAIR PPNG ��' CHANGE PROCEDURE <br /> p YES C] NO P YES DATE b u A f u 2-.1 C p 9 Y �Y ❑ OTHER <br /> u� SOURCE OF DISCHARGE TANKS1ONLYX.APACITY MATERIAL CAUSES) <br /> a TANK LEAK Qn UNKNOWN C2) E GAL_ ❑ FIBERGLASS ❑ OVERFLL ❑ RUPTUREIFALURE <br /> ¢ ❑ PIPINGLEAK AGE YRS STEEL ❑ CORROSION ;o UNKNOWN <br /> ❑ OTHER X1 UNKNOWN ❑ OTHER Q SPILL ❑ OTHER <br /> W w CHECKONCONLY <br /> O <br /> UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> z� <br /> d i ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ED <br /> IN PROGRESS E] SIGNED OFF{CLEANUP COMPLETED OR UNNECESSARY) <br /> NO ACTK)N TAKEN ❑ POST CLEANUP MONITORPIG IN PROGRESS ❑ NO FUNDS AVALABLE TO PROCEED ❑ EVALUAWC CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEC BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE R DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> Lu ❑ CONTAINMENT BARRIER{C8) ❑ EXCAVATE i TREAT(ET) Q PUMP A TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) QS NO ACTION REQUIRED(NN El OTHER(OT) <br /> {y- ��\ ��1/1`�^"hl�"L�i, '1 VLAS�L� -rh �Phl� ✓e_w�0�/�.L <br /> W \\ 1 <br /> 8 <br /> ' MIC S61�f1 <br />