Laserfiche WebLink
Now <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES 'FOR LOCAL-AGENCY USE ONLY <br /> F YES NO REPORT BEEN FILED 7 YES NO 1 HEREBY,CERTiFYTHAT 1 HAVE,DISTRIBUTED THIS INFORMATION ACCORDING TOTHE <br /> 01STRIBUTI SHOWN.ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE 2 CASE 0 <br /> -I M I Y SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGRE <br /> y ►ref . �-- (?.W ) (��-90 7 <br /> C33 I 61A <br /> w REPRESE TING Q OWNER/OPERATOR Q REGIONAL BOARD COMPANY OR AGENCY NAME <br /> ¢ .�OCAI AGENCY Q OTHER SQ .� 9it U (`0�( <br /> S kyAj <br /> ¢ ADDRESS C ' , ` jA�� �.{//� 2 S <br /> . W(n /\�/ \ • C� STATE C�, ZIP <br /> w NAME ICONTACT PERSON PHONE <br /> J <br /> ZUNKNOWN <br /> cc <br /> vOai as ADDRESS <br /> w <br /> ¢ STREET m eSTATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> 0 <br /> ADDRESS ^^'`` :54 c w ;sagr <br /> UO Z ` <br /> vim. crtv COUNTY ZIPw <br /> (= <br /> N `CRStSTREET <br /> LOCAL AGENCY AGENCY NAME CO TACT PERS?N PHONE / I <br /> y � c � 6 GIC/ <br /> Lu <br /> LLJ <br /> w REGKONALBOARD PHONE <br /> CL a <br /> N (�) NAME QUANTITY LOST(GALLONS) <br /> i wcz�a <br /> UNKNOWN <br /> Q J <br /> m Z( 2) <br /> ti- a UNKNOWN <br /> z DATE <br /> I DISCOVERED HOW DISCOVERED INVENTORY CONTROL Q SUBSURFACE MONITORING Q NUISANCE CONDITIONS <br /> w ►N MI o y Q TANK TEST �ANK REMOVAL a OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARG HECK ALL THAT APPLY) <br /> s UNKNOWN O REMOVE CONTENTS CLOSE TANK b REMOVE a REPAIR PIPING <br /> Lu <br /> HAS DISC u RGE BEEN STOPPED 7 r O REPAIR TANK CLOSE TANK b FILL IN PLACE E]CHANGE PROCEDURE <br /> 0 NO IF YES,DATE (:� l5j ` 0 3j oy Y Q REPLACE TANK Q OTHER <br /> 0 <br /> SOURCE OF ISCHARGE CAUSE(S) <br /> ¢ TANK LEAK 0 UNKNOWN F OVERFILL RUPTURE/FAILURE O SPILL <br /> cn U 0 PIPING LEAK a OTHER O CORROSION NKNOWN O OTHER <br /> W w CHECK ONE ONLY <br /> N C <br /> U UNDETERMINED SOIL ONLY 0 GROUNDWATER 0 DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w NO ACTION TAKEN 0 PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED 0 POLLUTION CHARACTER17ATION <br /> ¢ <br /> cr <br /> y O LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> U REMEDIATION PLAN a CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) 0 CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) a EXCAVATE b DISPOSE(ED) a REMOVE FREE PRODUCT(FP) a ENHANCED BIO DEGRADATION(IT) <br /> (SEE BACK KR MTAM) <br /> Z0 CAP SITE(CD) 0 EXCAVATE b TREAT(ET) Q PUMP 6 TREAT GROUNDWATER(GT)0 REPLACE SUPPLY(RS) <br /> O0 <br /> w I.- <br /> � CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) O TREATMENT AT HOOKUP(HU) a VENT SOIL(VS) <br /> ¢ F__j VACUUM EXTRACT(VE) Q OTHER(OT) <br /> M <br /> z ._ <br /> z <br /> w <br /> 0 <br /> O <br /> U <br /> HSC 05(SW <br />