Laserfiche WebLink
N0 -we <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FLED? 1 HEREBY CERTIFY THAT I AM A DESIGNATED GOVE N? k4ENT EMPLOYEE AND 7HA7 I HAVE: <br /> a S <br /> YES dN0 YES 0 NO REPORTED THIS INFORMATION TO LOCAL OFFICIALS PLMANT TO SECTION 25180.7 OF <br /> REPORT DATE CASE a THE <br /> �HEALTH <br /> �AND SSAFTY CODE <br /> �,p <br /> M M r v SIGNED <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGN TU RE <br /> Q <br /> REPRESE ING OWNERIOPERATOR REGIONALBOARD COMPANY OR AGENCY NAME <br /> Q � ! r <br /> O LOCAL AGENCY OTHER A J /G T <br /> a <br /> ADDRESS � Q � ^� 9500 <br /> gTREE7 CITY STATE IP <br /> NAME CONTACT PERSON PHONE <br /> ---I- I--] UNKNOWN ) V-29 3 <br /> aADDRESS <br /> ,E <br /> STREET CITY <br /> STATE P <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> rjz'&c> LF?e <br /> h ADDRESS <br /> lyj <br /> crry <br /> HCROSS STREET TYPE OF AREA F]OOMMERCLALZj INDUSTRIAL 0 RURAL TYPE OF BUSINESS O RETAIL FUEL STATION <br /> RESIDENTIAL [::]OTHER a FARM a OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> g w H J� E�-{ L ,ei Cor v t--L.,+ L142 8-3y 2 l) <br /> w� <br /> M L" REGIONAL BOARD PHONE <br /> C ✓k,rd q C ( ) <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> (n <br /> Lu ��T�OLEv,�1 urxNowN <br /> (2) <br /> UNKNOWN <br /> i DATE DISCOVERED / HOW DISCOVERED a INVENTORY CONTROL a SUBSURFACE MONITORING a NUISANCE CONDITIONS <br /> /n E] TANK TEST TANK REMOVAL OTHER <br /> r <br /> LL1 M M D --- <br /> I ~. DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN E] REMOVE CONTENTS REPLACE TANK a CLOSE TANK <br /> cr M M D .1 Y1 r _ <br /> p HAS DISCHARGE BEEN STOPPED? F REPAIR TANK REPAIR PP14G CHANGE PROCEDURE <br /> p Q YES [:] NO IF YES,DATE .1 M1 DI D r r [] OTHER <br /> Lu SOURCE OF DISCHARGE TANKSONLYCAPACITY MATERIAL CAUSE(S) <br /> F TANK LEAK UNKNOWN _ GAL. FIBERGLASS a OVERFILL a RUPTUREFALURE <br /> PIPING LEAK AGE _ YRS �STEEL CORROSION ©UNKNOWN <br /> cc f <br /> 0 OTHER a UNKNOWN 0 OTHER SPILL 0 OTHER <br /> w CHECK ONE ONLY <br /> UNDETERMINED SOIL ONLY a GROUNDWATER DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> � CHECK ON ONLY <br /> Q< SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cr <br /> U y NO ACTION TAKEN POST CLEANUP MONITORING IN PROGRESS NO FUNDS AVAILABLE TO PROCEED EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 0 <br /> El CAP SITE(CD) EXCAVATE 6 DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> M� F-] CONTAINMENTBARRIER(CS) ED EXCAVATE 6 TREAT(ET) PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> El TREATMENT AT HOOKUP(HU) NO ACTION REQUIRED(NA) OTHER(OT) <br /> f�-(JJ?TH�� 5rTE 19515EZ"EivT. INJC-L remit �'gUiR�7� Tc ��"T��M�rvE <br /> y <br /> I lfE lY,4TUiC DF C"X,TENT <br /> NSC 05(z;l <br />