Laserfiche WebLink
9 u3a, <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br /> TORIOCA 'AGENCtUSE ONLY ..... <br /> REPORT BEEN FILED 7 <br /> El YES P<NO YES NO <br /> II ERm'dE FYTHATAHAVEDISTRIBUTEDTHISINFbRMATION'ACCORDINGTOTHE <br /> ❑ <br /> pl$TR 18UT SFl NON THE INSTRUCTION SKEET gN'THE BACK PAGE OF TH FORM <br /> REPORT DATE CASE# <br /> � �+ c !er . <br /> M I u ll qY <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE /r <br /> - � G (,Z 0.33 <br /> w co <br /> REP ESENTING E—) OWI+lER10PERATOR ❑ REGIONAL BOARD COMPANY O AGENCY NAME <br /> 0 CALAGENCY ❑ OTHER � s� <br /> m ADDRESS //►f� /ice/_ �I� �fP����\ ///y ///��� <br /> V STREET ✓ J/V /STATE Z � <br /> /NA/Mco ME` '�j + �f [7 T CONTACT P RSON PHONE p /PIT f <br /> z L!i V F-1 IV Q "`! Akr-4, !V ' ❑ UNKNOWN ��I L-, ( �0��' $`S¢ 1 f 1 <br /> Lu <br /> ti a ADDRESS (/ //�I/ /� � µ1 y/�L7 <br /> � ll� ( STREET �L.T Orly 4 • `�!u sTaTE �./t IP L 3 0 <br /> FACILITY NAME()F APPLICABLE) OPERATOR PHONE <br /> Q POIOZS QQ liKI L96N CO <br /> ADDRESS r �AVR' [/ r J��/�y/ �//� (,/I L/�- �y y <br /> W STREET ,/D"�+ f r GITY ��T" ��'�1��7 COUNTY �7 ZIP�n <br /> v~-i CROSS STREET <br /> cry LOCAL AGENCYAGENCY NAME <br /> E CONTACT P R P PHONE <br /> z�' �4 fir` 1 n C <br /> wU <br /> w w REGIONAL BOARD PHONE <br /> a C7 <br /> y [1) NAME QUANTITY LOST(GALLONS) <br /> 00 <br /> Lu <br /> �� 4-a <br /> Z>J p [KNOWN l/�, <br /> U) (2) may/ <br /> ❑ 'UNKNOWN <br /> Iz z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CON ROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONSLu <br /> w SMI-3 MI Z D `�/7 <br /> DI y Y ❑ TANK TEST TANK REM0VAL ❑ OTHER (� <br /> a DATE"DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑REMOVE <br /> w Y CONTENTS I��LOSE TANK&REMOVE ❑REPAIR PIPING M M D D Y <br /> HAS DISCHARGE BEEN STOPPED? ❑REPA R TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> E YES ❑ NO IF YES,DATE II ❑REP CE TANK ❑OTHER <br /> M Mi <br /> Dil D Y Y <br /> SOURCE OF DISCHARGE CAUSES) <br /> I U) F--] TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> U ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w CHECK ONE ONLY <br /> U ❑ UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINK I G WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w E:] NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN UBMITTED POLLUTION CHARACTERIZATION <br /> cc I <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> c1 ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNt IECFSSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> (SEE BACK FCA WYARS) <br /> 4 Z ❑ <br /> fl O CAP SITE(CO) ❑ EXCAVATE&TREAT(ET) E] PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> a ❑ CONTAINMENT BARRIER(CB) E] NO ACTION REQUIRED(NA) E] TREATMENTAT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> ,. <br /> ZM I`� ��KCadr �-� + l W c(ts �z2/�9 . S� l�vrsi <br /> 3zZ �g. sf U��.s d;s �p ���-5��` P�s C a 6z eco CM 8A, rem ,, CSI �) <br /> / u S S - (-S r gr a ,� rn�rW �'iv Al kl4?` <br /> HSC OS I&M <br />