Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)!CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OFEMERGENCY SERVICES TORLOCALAGENCY,USEON4Y <br /> ❑ REPORT BEEN FLED 7 E]YES rq 1 HERE W.:'aFIT IFY:TIi T I AM J1:QESIGNATEU GQV (NMENi EMPLOYEE AND THAT ATTHAVE <br /> YES No <br /> RE?ORTIED;THis:.1OEQ(AMAT)ON TO LOCAL; FICI)U S. ANT:70 SECTIONip <br /> 25180 7 OF: <br /> REPORT DATECASE 11 TH6}IEAI TH.�EJD SAFT�f CODE <br /> 1 u I r 1 r SILiNED GATE. ' <br /> NAME OF INDIVIDUAL FLING REPORT PHONE SIGNATURE <br /> REPRESENTING ❑ OWNER/OPERATOR REGIONAL BOARD COMPANY OR AGENCY NAME �.,,, " <br /> LACAL AGENCY ❑ OTHER ..�f�N �/a!`}Q Gt[i� Lo .A <br /> c -(- �l CJY CT H J i 5-rpjC <br /> S <br /> ADDRESS //�� R �] /�Q py !1 <br /> 9( V 6 /"STREET C[!Y llsolxk Vz STATE zr I <br /> NAME CONTACTPERSON PHONE yf/� <br /> c ��LlU A L � <br /> �� Q S�dU UNKNOWN O y <br /> a <br /> ADDRESSL-lift I tA*H <br /> ZIP <br /> s <br /> .! Crtr <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> v G%7o-r- <br /> u ADDRESS cm COUNTY <br /> t <br /> CROSSSTREET TYPEOFAREA ❑COMMERCIAL OINDUSTRIAL❑RURAL TYPEOFBUSINESS ❑ RETAIL FUEL STATION <br /> h ❑RESIDENTIAL ❑OTHER ❑ FARM 0 OTHER <br /> LOCAL AGENCY AGENCY NAME A f CONTACT PERSON PHONE / '` <br /> 2,4 <br /> REGIONAL BOARD PHONE <br /> lLI NAME QUANTITY LOST(GALLONS) <br /> n '�Y a� Q l J ❑ UNKNOWN <br /> (� ❑ UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> O <br /> ml MI <br /> E] TAW TEST TANK REMOVAL E] OTHER _ <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> �> tx <br /> UNKNOWN ❑ REMOVECONTENTS ❑ REPLACE TANK CLOSE TANK <br /> Ml M o o v v ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> HAS DISCHARGE BEEN STOPPED? <br /> 1 p ❑ YES ❑ NO IFYES,DATE M n n r r ❑ OTHER <br /> SOURCE OF DISCHARGE TANKS ONLYICAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK �g UNKNOWN l/ GAN.. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREfALURE <br /> ❑ PIPING LEAK AGE YRS STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w CHECK ONE ONLY <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> w 0 NO ACTION TAKEN [D POST CLEANUP MONITORING IN PROGRESS —] NO FUNDS AVAILABLE m PROCEED [:] EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 4 ❑ CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ ENHANCED BIODEGRADATION(IT) <br /> REMOVE FREE PRODUCT(FP) ❑ <br /> a PUMP,&TREAT GROUNDWATER(GT) E] REPLACE SUPPLY(RS) <br /> c� ❑ CONTAINMENT BARRIER(CB) F-1EXCAVATE a TREAT(ET) ❑ <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> 5tf� NSSe5sN2 GviGG �e- <br /> Yfr Li a f�-t r h rte.-7f"' or <br /> Ca ��'•� �'i <br /> r u ,R� by He,, a��-'-010 . <br /> HSC 0614671 <br />