UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY F7 YES �K NO REPORT BEEN FILED? YES NO 1 HEREBY CERTIFYTHAT 1 HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE ❑ DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. REPORT DATE / ,Vr� CASE a oM 1 MI s D 1 Y SIGNED DATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE m A l LsQ no w la (2L -�84g C��),L" w REPRESENTING ❑ OW OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME cc Jd LOCAL AGENCY ❑ OTHER eLy, P s-ct I V y wi&4 fzz� ,��e l� ��r�I D ¢ ADDRESS li `''�� Y/� U A'vQ w-C ? R tom' S*n%l vl CA- x5202 STREET CITY STATE ZIP w NAME CONTACT PERSON PHONE z A c / �� ❑ UNKNOWN �, OCL a ADDRESS p. 'acx o GA G CQ VOL -6D5 I STREET CITY STATE ZIP FACILITY NAME(IF APPLICABLE) OPERATOR eC) V1 PHONE 412 CD (od (Zoq) 8v9- 0d7 U ADDRESS w STREET CITY COUNTY ZIP ~ CROSS STREET LOCALAGENCYAGENCY NAME MCONlT/A�C,TTPERSON P(HH(,OWNNEE U J3 (wLOlc ?fJ- etiu w w REGIONAL BOARD 1 PHONE O �a CV y (1) NAME QUANTITY LOST(GALLONS) w LLJ � E SI I ►'lam `l rolQt t�Na NlY� Z> D �S UNKNOWN cn z (z) ❑ UNKNOWN v Z DATE DISICOVERLu REHOW DISCOVERED INVENTORY CONTROL SUBSURFFAC � ED MONIT RIG NUISANCE CONDITIONS MI ` MI "JDI 1 DI DY Y ❑ TANK TEST ❑ TANK REMOVAL O OTHEL11 0R ` I � ❑ r r m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) QUNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING w M M D D Y V > REPAIR TANK CHAN HAS DIS cn YESRGE BEENO TIDE YES,DATE CDI DI ///] ❑REPLACE TANK ❑ OTHER rNFll IN�PILA� n'^CnH AN -PROCEDURE SOURCE OF DISCHARGE CAUSE(S) J w 5 ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL w v ❑ PIPING LEAK ❑ OTHER ❑ CORROSION -25.�I1NKNOWN ❑ OTHER Lu nw CHECK ONE ONLY L) UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY Z NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION j N ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) J (SEE BACK FOR OCTA ) o p ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) E:] TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) ¢ ❑ VACUUM EXTRACT(VE) OTHER(OT) P S G sf: Vv1evy+ \/U-Lu b2 to Irv�,�- -�!lQ �✓lc� �c-��v�-- o�- U HSC 0.5(890)