Laserfiche WebLink
EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />❑ YES NO REPORT BEEN FILED? ❑ YES ❑ NO <br />REPORT DATE I CASE# <br />..I 111 � 71 al <br />NAME OF INDIVIDUAL FILING REPORTPHONE <br />( <br />SIGNATURE <br />e <br />®0 <br />REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONALBOARD <br />COMPANYORAGENCYNAME <br />O <br />LOCALAGENCY ❑ OTHER <br />a <br />cw <br />DR SS ox �Loo <br />3TREEi CITY1 STATE 21P <br />y♦w <br />NAME Vo CON ACT PERSON PHONE <br />❑ UNKNOWN <br />w <br />ADDRESS <br />60 <br />w <br />>P er ETRE C STATE 3p <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />j"F <br />/PHONE <br />Qor� <br />aU <br />ADDRESS <br />l <br />oyO <br />STREET CITV COUNTYzip <br />hCROSS <br />STREET TYPE OF AREA ❑COMMERCIAL ❑INDUSTRIAL ❑ R RAL TYPE OF BUSINESS ❑ TAII FUEL STATION <br />❑ RESIDENTIAL ❑ OTHER ❑ FARM ❑ OTHER <br />rn <br />LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br />w - <br />` �' i <br />w <br />2 <br />REGIONAL BOARD PHONE <br />(1) NAME QUANTITY LOST (GALLONS) <br />UNKNOWN <br />gu" <br />edt <br />(2) <br />�i <br />❑ UNKNOWN <br />z <br />DATE DISCOVERED <br />6-1 <br />HOW DISCOVERED 0 INVENTORY CONTROL E] SUBSURFACE MONITORING F-1NUISANCECONDITIONS <br />Q1 T. Y Y1 <br />5K TANK TEST E:]TANK REMOVAL ® OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />W <br />.1 MI D D V Y1 15a UNKNOWN <br />REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br />p <br />❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED ? <br />❑ YES ❑ NO IF YES, DATE M .1 D C v v <br />❑ OTHER <br />wSOURCE <br />D <br />OF DISCHARGE <br />❑ TANK LEAK UNKNOWN <br />TANKS ONLYICAPACITY MATERIAL <br />GAL. ❑ FIBERGLASS <br />CAUSE(S) <br />❑ OVERFILL ❑ RUPTURE/FAILURE <br />❑ PIPINGLEAK <br />AGE111 6 YRS ❑ STEEL <br />❑ CORROSION ❑ UNKNOWN <br />❑ OTHER <br />❑ UNKNOWN ❑ OTHER <br />❑ SPILL ❑ OTHER <br />w w <br />a <br />CHECK ONE ONLY <br />O <br />UNDETERMINED E:] SOIL ONLY D GROUNDWATER a DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />cutj <br />CHECK ON' ONLY <br />❑ SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />cc <br />U <br />❑ 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 />❑ CAP SITE (CD) ❑ EXCAVATE & DISPOSE (ED) REMOVE ❑ ❑ ENHANCED BIODEGRADATION�(I] <br />PUMP & TREAT GROUNDWATER (GT) REPLACE SUPPLYDE <br />❑ CONTAINMENT BARRIER (CB) ❑ EXCAVATE & TREAT (ET) ❑ ❑ <br />REQUIRED (NA) ❑ OTHER (OT) <br />❑ TREATMENTATHOOKUP (HU) ❑ NO ACTION REQUIRED <br />t pIII <br />z <br />w <br />5 i 1� 1 <br />