Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)1 CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FRED 7 ❑ YES ❑ NO I HEF EV CE�YTHAT)HAVE DISTRIgUTEDTHIS 31lFdiMAT10N ACCORDING TO THE <br /> ❑ YES � NO DI.STRffiUT[CN SHOWN ON THE TNST anON SHEEP ON THE$ACK PAGE OF THIS Fib! <br /> REPORT GATE <br /> CASES _� <br /> lL1TE <br /> NAME OF INDIVIDUAL FILING REPORT <br /> PHONE TORE <br /> �c.�►-� �cashrQk�. iZG9? 410�-�:33� � <br /> m ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> REPRESENTING ❑ OWNERIOPERATOR <br /> cr LOCAL AGENCY ❑ OTHER <br /> y1+t,D Ute �+��� <br /> s ADDRESS i,' '` S loC 'roll �C `fSZQ� <br /> 504 <br /> e• c"to c.- Aq G G� STALE ZIP <br /> CONTACT PERSON PHONE <br /> w NAME <br /> H ` ❑ UNKNOWN Fr-ax k R c.ur I <br /> CL ADDRESS �] � �G CAQS�Q� <br /> � r '�l�d`a C!T"/ STATECc P <br /> STREV OPERATOR PHONE <br /> FACILITY NAME(IF APPLICABLE)S-8) Z A 6 �aw�r (2m) <br /> 6 �c d d t <br /> c~4i ADDRESS yd�uLw t2 <br /> 0 8200 1�1. �wc19 St'cr.�-toln caurmr <br /> } <br /> w CROSS STREET <br /> AGENNCY CY NAME CONTACT PERSON PHONE <br /> L S uiPHO <br /> w< �uu-CA (Z„d4)�Ca�s-Q <br /> v NE <br /> zREGIONALBOARD r 1 <br /> 4l 1 <br /> R W NAME QUANTITY LOST(GALLONS) <br /> H (t) UNKNOWN <br /> 0 Lu G--gsojcn G <br /> J <br /> m� m ❑ UNKNOWN <br /> �? <br /> yBSURFACE MONITORING C3 NUISANCE CONDITIONS <br /> z DATE DISCOVERED F�v+r DISCOVERED ❑ INVENTORYCONTROL SU❑ <br /> w / I / T C:] TANK TEST ❑ TANK REMOVAL ❑ OTHERu METHOD USED TO STOP DMCHAR E ICNECK ALL THAT APPLY) <br /> < DATE DISCHARG=E BEGAN <br /> ` UNKNOWN ❑REMOVE CONSENTS ❑CLOSE TANK&REMOVE REPAIR PIPING <br /> Lu HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR <br /> T TANK 0 CLOSE TANK S FILL IN PLACE ❑CHANGE PROCEDURE <br /> o' <br /> YES ❑ NO BYES.DATE f ' � p r�� C] OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> UNKNOWN ❑ OVERFRL RUPTUREIFALURE ❑ SPLL <br /> a [7 TANK LEAK <br /> CORROSION UNKNOWN ❑ OTHER <br /> PIPING LEAK CDOTHER ❑ <br /> w w CHECK ONE ONLY <br /> 4 a GROUNDWATER DRWIaH(3 WATER -ICHfCK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> v UNDETERMINED SOL ONLY ❑ ❑ <br /> CHE ONE ONLY CD POLLUTION CHARACTERIZATION <br /> ❑ NO ACTION TAK <br /> z EN ❑ PRQSMINARY SITE AS.SESSMEiVTN10RKPWV SUBMITTED <br /> s t. ❑ LEAK BEING CONFIRMED ❑ ❑ POST CLEANUP MONITORR�O IN PROGRESS <br /> t PRELIMINARY SITE ASSESSMENT UNDERWAY <br /> D ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CDCLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ED EXCAVATE&DISPOSE(m1 ❑ REMOVE FREE CT PRODUIFP) ❑ <br /> ENHANCt�SIC DEGRADATION(IT) � <br /> °' RM Wf'� PUMP b TREAT GROUNDWATER(GT)C] REPLACE SUPPLY(RS) <br /> �z ❑ c °"CAP SITE(CO) CD EXCAVATE A TREAT(£T) ❑ VENT SOL(VI) <br /> d 4 ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REOUTAED MA) TREATMENT AT HOOKUP(HM ❑ <br /> ❑ VACUUM EXTRACTIVE) ❑ OTHER(011 <br /> ua-c,cl <br /> CSO rc. r>L4-+C.. Lid0,:kov- <br />