UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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,Z:"2- tl 15 UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVI FOR LOCAL AGENCY USE ONLY REPORT BEEN FILED 7 I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TOTHE ❑ YES NO ❑ YES NO AISTA UTIONEI)7TFiUCTIDN SHEET ON THE BACK PAGE Of THIS ORM REPORT DATE CASE CASE+t / (J v M 2-I IGNED DATE NAME OF INDIVIDUAL FILING REPORT PHONE SI w REPRESENTING ElOWNER/OPERATOR ❑ REGIONAL BOARD COM`P`ANY OR AGENCY NAME cc OCALAGENCY ❑ OTHERcc ADDRESS Z>A'/(cJ/ _/� ,(� G•� I ,' /��i - STREET STATE ZIP crry w NAME CONTACT PERSON / /� PHONE /``�j z Gr•S. l�E�T o� rlClLvLy�� ❑ UNKNOWN /^SCI Y�r c�nl t� rL-LE/� (�i�) 77/ I—z53 a a ADDRESS 5�� IPOI4•I/Iy ��/¢— q�61G' 541 cc ZlZI-G Z STREET CITY STATE ZIP FACILITY NAME(IF APPLICABLE) OPERATOR PHONE 0 !/��iq-' iL ��1�Fe✓.�iio,`1 y l�F (z� )-7 Z 7 U ADDRESS 0 Z00, / I. l �.�c�7T Lo ciLGFa�t� s-`�'• �'- �G�z 3-7 STREET CITY COUNTY Zip w CROSS STREET Q LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE z �, CO. — (-� ,�iQ•i� 7T '6v,E1•l.d_ ( Zoq) 4/6 ' C 533 w uj REGIONAL BOARD PHONE N (i) NAME QUANTITY LOST(GALLONS) W 0 z> /'ji UNKNOWN a� In z (Z) KNOWN t DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING E] NUISANCE CONDITIONS LLJ m OMI V D DI YI v ❑ TANK TEST �f NK REMOVAL ❑ OTHER , m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) Q UNKNOWN E]REMOVE CONTENTS ❑CLOSE TANK 8 REMOVE E:]REPAIR PIPING W M M 0 D Y Y p HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK 8 FILL IN PLACE ❑CHANGE PROCEDURE o ❑ YES ❑ NO IF YES,DATE M MI D 0 y Y ❑REPLACE TANK OTHER SOURCE OF DISCHARGE CAUSE(S) tr U) ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE SPILL U v ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER Lu En a CHECK ONE ONLY ❑ IL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) UNDETERMINED � CHECK ONE ONLY w F7 NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION Z)cn ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS 0 ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE d DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) J tSEE BACK FOR XTA") 0 0 ❑ CAP SITE(CD) ❑ EXCAVATE 8 TREAT(ET) PUMP 8 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) Lu w 0 ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) Q ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) XOv/ew a< rfLv�-7'S F,e�.�-r �i4��t 1� /CE�rov�dL �rda/�.�i S�l�Ca�t7T /�/•�T�l w �rQ?�/f�G �iT� � �E�f'T �iiGG /'�E �E4�i.�✓� ?D s`�7'.Ei�'i4<NE 0 U HSC 05(890)