Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />FOR LOCAL AGENCY USE ONLY . <br />REPORT BEEN FILED 7 <br />[� YES x,No ❑ YES NO <br />I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br />REPORTEP THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br />THE IfYTH AND SAFT D <br />REPORT DATE <br />CASE <br />0-19-10 o ?YlY <br />SIGNED DA E <br />NAME FILING REPORT- <br />PHONE` <br />SIGNAT E <br />} <br />WPIND <br />�1L <br />m <br />0 <br />- <br />REPRES TING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD <br />COMPANY OR AGENCY NAME <br />¢ <br />LOCAL AGENCY ❑ OTHERL <br />Q <br />ADDRESS <br />/aoi F "192COTDAJ <br />STREET CITY STATE zl.5 s <br />L9 <br />NAME <br />CONTACTPERSON <br />PHONEco <br />zmb�,/ <br />-UNKNOWN <br />JyZ <br />- 7 <br />Qa <br />cc <br />ADDRESS <br />STRE CRY STATE ZIP <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR <br />PHONE <br />/(� <br />Va <br />ADDRESS <br />/JTD <br />CITY�f)� <br />STREETCOUNTY ZIP�� <br />CROSS STREET <br />TYPE OF AREA ❑ COMMERCIAL [:]INDUSTRIAL RURAL <br />TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br />0 RESIDENTIAL ❑ OTHER <br />❑ FARM ❑ OTHER <br />LOCAL AGENCY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />r w <br />w��u_c��:�c <br />VL_s�` <br />ul w <br />R=GIONALBOARD <br />PHONE <br />G <br />Gb ` ,� <br />(1i) NAME QUANTITY LOST (GALLONS) <br />W <br />J �,, ® UNKNOWN <br />v� O <br />(2) <br />❑ UNKNOWN <br />Z <br />DATE DISCOVERED <br />HOW DISCOVERED INVENTORY CONTROL CI SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />GODI S <br />❑ TANK TEST TANK REMOVAL ❑ OTHER <br />.I Y Y <br />CH3 -.I <br />1CAAT�EIDDII_SCHARGE <br />BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />w <br />_ M1_ML�o v v UNKNOWN <br />REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br />p <br />❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED 7 <br />o <br />❑ YES D NO IFYES,DATE <br />OTHER a� <br />M M o D v Y <br />_J1/qdGT <br />w <br />SOURCE OF DISCHARGE <br />TANKS ONLY/CAPACITY MATERIAL <br />CAUSE(S) <br />cn <br />❑ TANK LEAK [X UNKNOWN <br />IM-0, GAL. FIBERGLASS <br />❑ OVERFILL ❑ RUPTUREiFAILURE <br />Lo <br />❑ PIPING LEAK <br />AGE YRS STEEL <br />❑ CORROSION � UNKNOWN <br />❑ OTHERA <br />UNKNOWN ❑ OTHER <br />`� <br />❑ SPILL 0 OTHER <br />w w <br />CHECK ONE ONLYw <br />a- <br />❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />H <br />CHECK ONE ONLY <br />Ld <br />a cc <br />❑ SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />¢� <br />v rn <br />❑ NO ACTION TAKEN 0 POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED 0 EVALUATING CLEANUP ALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />z <br />❑ CAP SITE (CD) ❑ EXCAVATE 8 DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />00 <br />w <br />❑ CONTAINMENT BARRIER (CB) ❑ EXCAVATE & TREAT (ET) ❑ PUMP d TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />¢ <br />❑ TREATMENT AT HOOKUP (HU) ❑ NO ACTION REQUIRED (NA) ❑ OTHER (OT) <br />�wi(-L a ;zc-a(jfi26b 7DDFS' 'Mrn)E <br />ExiC�/i OF corpr?+M A,0f--�O—)e, 05 PC urRrb ray T7,1r-- �'F'�G1OP-04rZ: ✓Y- -vc�/ <br />� <br />_ <br />HIS S/ I � /s �- `� D � �0 M •�� TI�QC,�l;pjilJ Cu!� T�7z � t`S l=��f <br />l HSC05(N87) <br />G - u�- <br />