Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCALiAGENCY USE ONLY <br /> YES NO REPORT BEEN FILED? D YES ❑ NO )(#(READ T#(t INFORMAT11N1 TO SLOCAL F(G(/N Sw URSUANT�O 5E�25980 7AOF <br /> REPORT DATE CASE N THE HEAUM AND SAI.... )DE <br /> M M D D Y j <br /> .$IFIE® 9kiTE:.: <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> ym j//P"'4 <br /> REPRESENTING ❑ OWNER/OPERATOR ❑ EGIONAL BOARD COMPANY ORSft AGENCY NAME <br /> 0O LOCALAGENCY ❑ OTHER JQAaJA l^ w <br /> a <br /> w DORESS <br /> el a o <br /> STREET CITY STATE IP <br /> LqNAME CONTACT PERSON PHONE <br /> ca iUNKNOWN <br /> a ADDRESS <br /> UJ <br /> f STRE CIPy SPATE CA <br /> ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> z } <br /> O <br /> .j ADDRESS <br /> fVj b JAI <br /> STREET C(fY COUNTY ZIP <br /> mCROSS STREET ` TYPE OF AREA ❑COMMERCIAL❑INDUSTRIAL❑RURAL TYPE OF SINESS ❑ RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER � FARM O OTHER <br /> I am PtaLOCAL AGENCY AGENCY NAME ® CONTACT PERSON PHONE <br /> w� 1. CA fjwA(' ly <br /> w� REGIONAL BOARD PHONE <br /> CL <br /> VR A <br /> (t} NAME QUANTITY LOST(GALLONS) <br /> wA, <br /> S2 UNKNOWN <br /> (2 <br /> ❑ UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL O SUBSURFACE MONITORING Q NUISANCE CONDITIONS <br /> M M D D Y y TANK TEST E::] TANK REMOVAL ❑ OTHER <br /> I DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w <br /> mi mi DI DI Yl Yl ❑ UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> > HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK E] REPAIRPIPING ❑ CHANGE PROCEDURE <br /> ® ❑ YES ❑ NO IF YES,DATE M1 M o D Y tl ❑ OTHER <br /> U, <br /> SOURCE OF DISCHARGE TANKS <br /> ONLYICAPACITY MATERIAL CAUSE(S) <br /> TANK LEAK UNKNOWN _/_00 GAL. 0 FIBERGLASS ❑ OVERFILL O RUPTURE/FAILURE <br /> ❑ PIPING LEAK AGE YRS STEEL ❑ CORROSION ❑ UNKNOWN <br /> E:] OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w w CHECK ONE ONLY <br /> CL ❑ UNDETERMINED E:] SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> F_� <br /> a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cc <br /> V NO ACTION TAKEN E:] POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 0 z ❑ CAP SITE(CO) a EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> A <br /> ( j0 tj ,` <br /> will ® / < b <br /> c4 <br /> HSC 08(w <br />