UAR/PROP 65_PRE 2019 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY STATE TANK ID HAS STATE OFFICE OF EMERGENCY SERVICES YES hIV� NO REPORT BEEN FILED? ❑ YES LN NO //R^^EPORT DATE LOCAL CASE It REGIONAL BOARD CASE N US EPA ID # VM 3M 3D /D LAY �Y NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE / Y ) 1 m orad m REPRESENTING ❑ LOCAL AGENCY ❑ OTHER COMPAN OR AGENCY NAME W OWNER/OPERATOR ❑ REGIONAL BOARD C GI O W ADDRESS Ir STREET •�illl'-�5 A� C -5'99; r:% STATE ZIP i F NAME J�' �v CONTACT PERSON PHONE �j�y / ` z0d rlA�t��7� �lC,/�l�lE ��p ❑ UNKNOWN ��f fi2/' JJEI.IJr'�� /(W7 ) /.9` l�y�a� CL W ADDRESS ^� 4 �•� /1�7 A� 1.J� wM �1 S `�'RV `� CITY STATE ZIP tt m STR T FACILITY NAME (IF APPLICABLE) OPERATOR PHONE 2 /' ell ~ ADDRESS Oxy / / , ��{/, C- O U JlQ l�l S t' Gam/1 912-�� L11 vt J STREET CITY COUNTY ZIP W CROSS STREET TYPE OF AREA ® COMMERCIAL ❑INDUSTRIAL TYPE OF BUSINESS LK RETAIL FUEL STATION F- a 1E]RESIDENTIAL ❑RURAL ❑OTHER F_1 UNKNOWN ❑OTHER LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE z- REGIONAL BOARD Li U W W aid � Nit ) 161 d 0 TSCD w CAS N (ATTACH EXTRA SHEET IF NEEDED) NAME QUANTITY LOST (GALLONS) UO _ a J (11 i,G/ Ja-- j C 1 L I II N K N O W u~O m> :) (2) I �❑ UNKNOW //D{{ATE DISCOVERED HOW DISCOVERED F-] INVENTORYCONTROL ❑ SUBSURFACE MONITORING TANK jH VM M /D I Op 7y ❑ ROUTINE MONITORING REMOVAL L] NUISANCE CONDITIONS �._� OTHER: wZ W DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) OW M M D DI YJ YJ UNKNOWN ❑ REMOVE CONTENTS �I REPLACE TANK nCLOSE TANK m HAS DISCHARGE BEEN STOPPED? L_.�REPAIR TANK u REPAIR PIPING [:]CHANGE PROCEDURES YES D NO IF YES, DATE I MI MI D DI Y Y ❑OTHER W S URCE(S) OF DISCHARGE TANKS ONLY/CAPACITY GAL CAUSE(S) j TANK LEAK ❑ UNKNOWN I I ' ❑OVERFILL ❑CORROSION ¢ AGE YRS. X UNKNOWN W ❑PIPING LEAK MATERIAL i❑RUPTURE/FAILURE E]SPILL u ❑STEEL ❑ FIBERGLASS m ❑OTHER (SPECIFY) ❑OTHER NNKNOWN [:]OTHER RESOURCES AFFECTED WATER SUPPLIES AFFECTED THREAT- - YES NO THREATENED UNKNOWN YES NO ENED KNOWN WELLS I- AIR (VAPOR) ❑ ❑ EJ C] PUBLIC DRINKING ❑ ❑ ❑ El W SOIL (VADOSE ZONE) WATER --^ LL ❑ ❑ ❑ PRIVATE DRINKING ❑ �I ❑ o U. GROUNDWATER ❑ ❑ �� WATER LJ W K SURFACE WATER OR STORM DRAIN EJ E] El INDUSTRIAL ❑ ❑ ❑ ❑ UI•- BUILDING OR UTILITY VAULT ❑ El ❑ ❑ AGRICULTURAL ❑ ❑ E] E]O'¢ OTHER (SPECIFY) El El El OTHER(SPECIFY) 1:1 El EJ 1:1 W x GROUNDWATER BASIN NAME + O '� .S I ❑UNKNOWN COMMENTS: F- z z w E E 0 u COMPLETE AND ATTACH A CLEANUP TRACKING REPORT IF ANY CLEANUP WORK OR PLANNING HAS STARTED RSC 05 (10/85)