COMPLIANCE INFO_1987-1998 - Laserfiche WebLink

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EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES AOR LOCALACENCY USE ONLY REPORT BEEN FILED ? ❑ YES No YES NO 3 HEREBY CERTIFY THAT l AM A: f1I StCaNAT7t GOVERNMENT EMPLOYEE ANEd REPORTEE?<TH{S INFORMATION TO LOC #F(CIALS PURSUANT TO SECTION 25160.7 THEHEAIT}i REPORT DATE CASE# M o Y v 100 TE .: NAME OF INDIVIDUAL FILING REPO�RTw PHONE SIGNATURE /• / `/ cri) / REPRESEN ❑ OWNER/OPERATOR REGIONAL BOARD ❑ COMPANY OR AGENCY NAME R LOCALAGENCY ❑ OTHER ADDRESS STREET CITY STATE ZIP NAME CONTACT PERSON PONE N ❑ UNKNOWN a I Y w a ADDRESS w STREET' CITYVMASTATE P 20� FACILITY NAME (IF APPLICABLE) OPERATOR PHONE pvrl; 235 —111 ® a ADDRESS — Mloolx STREET . go-CTTY °, COUNTY ZIP N -]RURAL CROSS STREET TYPE OF AREA COMMERCIAL 0 INDUSTRIAL TYPE OF BUSINESS RETAIL FUEL STATION ❑ ❑� RESIDENTIAL E:]OTHER F7FARM ❑OTHER LOCM AGENCY AGENCY NAME CONTAC SOtI( PHONE 11 w54�� w REGIONAL BOARIV PHONE va[j W (I) N E QUANTITY LOST (GALLONS) E;PUNKNOWN D - ❑ UNKNOWN WN DATE DISCOVERED HOW DISCO D Q INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS TANK TEST E] TAW REMOVAL 0 OTHER /,,I r T r� Y v 1. DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) 1 Ee UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK w MI Td o 01 Yl Yl HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PPING ❑ CHANGE PROCEDURE p OTHER dJ E:] YES ❑ NO IF YES, DATEI ml O D Y v w SOURCE OF DISCHARGE TANKS ONLYCAPACITY MATERIAL CAUSE(S) --]TANK F LEAK UNKNOWN GAL. FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ PIPING LEAK AGE YRS ❑ STEEL ❑ CORROSION NKNOWN ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER w CHECK ON NLY U U NDE5TERMINED O SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECKO ONLY zN a SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) U N ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) z F-1CAP SITE (CD) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BK) DEGRADATION (IT) 00 2 ❑ CONTAINMENT BARRIER (CB) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) ❑ TREATMENT AT HOOKUP (HU) ❑ NO ACTION REQUIRED (NA) OTHER (07) z g nsuw(sroi).