Laserfiche WebLink
UNDERGROUND STORAGE TANK • ' rEASE (L <br />CONTAMI <br />EMERGENCY OF EMERGENCY SERVICEREPORT BEEN YES NO YES 0 <br />• <br />4• • .,, <br />REPORT DATE <br />r, <br />vHSC 05 (aW <br />cl(Ilf <br />NAME 00 IND VIDUAL FILING flEPOAT <br />PHONE <br />SIGNATURE--- <br />`w <br />®- • <br />m <br />e <br />w <br />REPRESENTING OWNER/OPERATOR ® REGIONAL BOARD <br />COMA OR AGENCY N <br />cr <br />a LOCAL AGENCY HER <br />cc <br />ADDRESS "C A <br />m <br />ST ET CITY / STATE ZIP <br />NAME ® PE t . PHONE <br />z r <br />UNKNOWN ! t ✓�® <br />00 a <br />w <br />ADDRESS <br />[ (,' <br />r j <br />STREET / CRY f STATE ZIP <br />FACILITY NAME IF APPLICABLE) <br />OP TO PHONE <br />zO <br />VAr-cl <br />ADDRESS ®/� ///►. r <br />giAock4n tj <br />w <br />STREET C ®COU ZIP <br />CROSS STA p V <br />MOCAR <br />O <br />L AL AGE Y I AGENCY NAME <br />r <br />CO T PERSONPHONE <br />w U <br />fA Cd <br />16w <br />w czw5 <br />REGION ORD f <br />PHONE <br />a¢ <br />W <br />(ID NAME QUANTITY LOST (GALLONS) <br />Z> <br />X h K UNKNOWN <br />CD z <br />(2) <br />�- <br />w <br />Q UNKNOWN <br />r <br />z <br />PATE DISCOVERED <br />HOW DISCOVERED ❑ INVENTORY CONTROL ® SU FACE NITORING F CE CONDITIONS <br />I <br />2 <br />MI M p Y <br />TANK TEST ® TANK REMOVAL OTHER �/ <br />m <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />a <br />p v �" UNKNOWN <br />®REMOVE CONTENTS CLOSE TANK 8 REMOVE REPAIR PIPING <br />Lu <br />REPAIR TANK 0 CL FILL IN CE CHANGE PROCEDURE <br />HAS DIS HAA E BEEN STOPPED ? <br />o <br />YES 0 NO IF YES, DATE 67 <br />O REPLACE TANK OTHER 14 IT <br />M o v v <br />ja <br />N c> <br />SOURCE OF DISCHARGE <br />TANK LEAK 0 LINK <br />CAUS (S) w <br />® OVERFILL ® RUPTURE/FAILURE SPILL c <br />® PIPING LEAK THER <br />❑ CORROSION F-� UNKNOWN THER Q. <br />aw Lu <br />CHECK ONE ONLY <br />v <br />❑ UNDETERMINED ❑ SOIL ONLY a GROUNDWATER 0 DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />CHECK ONE ONLY <br />Z 0 <br />® NO ACTION TAKEN ® PRELIM SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br />j9 <br />® LEAK BEING CONFIRMED ❑ P LIMINARY SITE ASSESSMENT UNDERWAY ED POST CLEANUP MONITORING IN PROGRESS <br />U <br />O REMEDIATION PLAN CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ® CLEANUP UNDERWAY <br />J <br />CHECK APPROPRIATE ACTION(S) a EXCAVATE & DISPOSE (ED) Q REMOVE FREE PRODUCT (FP) E] ENHANCED BIODEGRADATION (IT) <br />ISEE BACK FM DETA&M <br />a80 Z <br />® CAP SITE (CD) ® EXCAVATE & TREAT (ET) PUMP & TREAT GROUNDWATER (GT) [::] REPLACE SUPPLY (RS) <br />w a <br />cc <br />❑ CONTAINMENT BARRIER (CB) 10N REQUIRED (N TRE ENT AT H KUP (H VENT SOIL (VS) <br />VACUUM EXTRACT (VE) 021,0THER (OT) <br />l� r �f `"may 4t I',fL C 0!1 <br />z <br />Lu <br />2 <br />/// <br />ca et,( <br />(27 ra- (f oi-- <br />C`UV7 <br />g <br />vHSC 05 (aW <br />cl(Ilf <br />