SITE INFORMATION AND CORRESPONDENCE

Home Browse Search

?I- I UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT "I EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY.- NAME OUANTTTY LOST (GALLONS) �x I A YES NO REPORT BEEN FILED? ❑ YES No 1:} EREBY CERTIFY THAT- ( AM A -DESIGNATED GOVERNMENT -EMPLOYEE AND....AT l HAVE; (z) .::FIEPORTED THISWFORMATIOFf-TO-:LOCAL.,OFFICIALS E HEALTH AND 5AFTY OODE. . PURSUANT.-TO:SECTION.251$07-OF REPORT DATE CAS£ N I 3 0 HOWDISCOVERED C] INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS ❑ TANK TEST � TAMC REMOVAL O o v ❑ OTHER re -, DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) NAME OF INDIVIDUAL FILING REPORT M M o o v PHONE 1(2cai) El REMOVE CONTENTS ❑ REPLACE TANK �' CLOSE TANK SIGNATURE HAS DISCHARGE BEEN STOPPED ? f9 YES O NO IF YES, DATE Dcavid C L k., 40�r_ ❑ OTHER u� SOURCE OF DISCHARGE REPRESENTING ❑ OWNEWOPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME CAUSES) g LOCAL AGENCY OTHER foo0 GAL. Q FIBERGLASS Sc, La�� �e4IiL. NsA,-tit ❑ PIPING LEAK AGEYRS STEEL v �R y;� cc ADDRESS UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER w t CHECK ONE ONLY leo t fir~ $oc1�� e A 9SZo I ❑ UNDETERMINED NAME C" CONTAC7PERSON STATE p PHONE i c o✓✓ � q., ❑UNKNOWN � orr i �.... g �� c Lo i 4wk. n ADDRESS a t� ❑ CAP SITE (CD) CONTAINMENT EXCAVATE 6 DISPOSE ED ❑ 1 1 ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) R h STREET ❑ EXCAVATE & TREAT (ET) ❑ PUMP d TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) G S o 3 ❑ NOACTIONREOUIREO(NA) pT}{ER(fO7) FACILITY NAME (IF APPLICABLE) �et e�� wT�� CITY OPERATOR TF ZIP PHONE CovV,, o,+.. ♦f1116c ce �,. w (-.,tv-I Ract ) qW?- bis �02�"iREEr ti CROSS STREET OF AREA crry COMMERCIAL INDUSTRIAL Q RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION Fr "t1141 -t S� .! [[��RESQENT� E] OTHER [j FARM OTHER c9 LOCAL AGENCY AGENCY NAME CONTACTPERSON 2 PHONE. tu l Lu L REGIONAL BOARD PHONE. w o (11 NAME OUANTTTY LOST (GALLONS) �x I �S C • �• UNKNOWN (z) UNKNOWN i I" DATE DISCOVERED S Z �Yl HOWDISCOVERED C] INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS ❑ TANK TEST � TAMC REMOVAL O o v ❑ OTHER DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) w> M M o o v v UNKNOWN El REMOVE CONTENTS ❑ REPLACE TANK �' CLOSE TANK 9 p HAS DISCHARGE BEEN STOPPED ? f9 YES O NO IF YES, DATE ❑ REPAIR TANK REPAIR PANG ❑ CHANGE PROCEDURE DMI S.1 2_.j o1 ❑ OTHER u� SOURCE OF DISCHARGE TANKS ONLYCAPACITY MATERIAL CAUSES) El TANK LEAK UNKNOWN foo0 GAL. Q FIBERGLASS ❑ OVERFILL ❑ RUPTUREJFAILURE ❑ PIPING LEAK AGEYRS STEEL CORROSION UNKNOWN OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER w t CHECK ONE ONLY o�j ❑ UNDETERMINED SOIL ONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY i O SITE IN IN PROGRESS (DEFINING EXTENT OF PROBLEM) E] CLEANUP W pAOGRESS [] SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) U y NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) a t� ❑ CAP SITE (CD) CONTAINMENT EXCAVATE 6 DISPOSE ED ❑ 1 1 ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) BARRIER (CB) TREATMENT ❑ EXCAVATE & TREAT (ET) ❑ PUMP d TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) ATHOOKUP (HU) ❑ NOACTIONREOUIREO(NA) pT}{ER(fO7) �et e�� wT�� r a�-�.w �� ov�.r�.Y. 12-11 Ji t aSS�SSw�e.�f 4—