Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY ry <br /> ❑ y,� <br /> YES NO REPORT BEEN FILED? �YES O NO IHERE3YCERTIFYTHATI HAVEDIST UTEDTHIS INFORMATION ACCORDINGTOTHE <br /> �J <br /> DISTRI13UTI OWN ON THF,,IN UCTION SHEET ON THE BACK PAGE OF THIS' y 4 <br /> REPORT DATE( t CASE# <br /> oO J V D Y DATE <br /> NAME OF INDIVIDUAL V41NG R ORT PHONE SIGNATURE <br /> C3 <br /> OWN OPER T ❑ REGIONAL BOARD COMPANY OR AGE Y NAME <br /> w REPRESENTING <br /> g ❑ LOCAL AGENCY OTHER `( ^N <br /> cr ADDRESS U ![�a(^ <br /> STATE <br /> STREET `+�-� CIT' •�^�� ZIP <br /> w NAME CONTACT PE SON /PHONE SS <br /> zJ ` ) V <br /> 6 •❑ UNKNOWN <br /> a¢ ADDRESS <br /> cr CL C�WI' <br /> w <br /> STREET <br /> CITU STATE ZIP <br /> FACILITY NAME(IF APPLICABLE OPERATOR PHONE <br /> UADDRESS \ ►r �/� \x °1533 <br /> STREET O� Y 1 1� `� CITE' � � <br /> COU � U 1" ZIP <br /> Lu <br /> CROSS STREET <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z <br /> wu1A. \c -kevPrvA ( obi) ` w -34o <br /> w w REGIONAL BOARD PHONE <br /> �F\t s �� �G s��� (91b) QSS-3LVG <br /> (�) 1 ( /� (� NAME QUANTITY LOST(GALLONS) <br /> U Ow �'� LJIJl�C7„-I)� „�/1 ( S O UNKNOWN <br /> Z <br /> Q J <br /> F <br /> m z (2) <br /> cn ❑ <br /> � UNKNOWN <br /> DATE DISCOVEREDHOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> W Ml ),I ` oI oYI I v ❑ TANK TEST ❑ TANK REMOVAL OTHER C� �`�Y� of f <br /> m D!AATE DISCHARGE BEGAN S METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Q V M l u �� o v v ❑ UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED? G ❑REPAIR TANK O CLOSE TANK&FILL IN PLACE`1 CHANGE PROCEDURE <br /> 'nYES [:] NO IF YES,DATEI 1 MI 3oI o `v v ❑REPLACE TANK ® OTHER t <br /> 0 <br /> 'D SOU CE OF DISCHARGE CAUSES) <br /> j< ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE SPILL <br /> U)O ❑ PIPING LEAK OTHER�� 4 ❑ CORROSION ❑ UNKNOWN OTHER <br /> w w CHECK ONE ONLY <br /> v ❑ UNDETERMINED SOIL ONLY j ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z u) ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w <br /> cr <br /> U/n <br /> F-] LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY (� <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> ISEE BACK F( DETALS) <br /> a1 ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> o <br /> CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ OQ <br /> g o ❑ CONTAINMENT BARRIER(CB) E] NO ACTION RE IRED(NA TR ATME tyT AT H KUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ,� OTHER(OT) V �. <br /> owe ae Q�no����' �rv� C� ► P�"p I b s , <br /> cn <br /> w �,� Y P P <br /> ° tip S,t�vr 11nCv..r. ate. cu Wt'.t'`'` C, ' <br /> HSC 05(1190) <br /> ems•. �,A.�1��`skt <br />