Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY'.I: - <br /> REPORT BEEN FILED? I,HEREBY CERTIFY.THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE'. <br /> [D YES NO ❑YES NO 'REPORTED THIS INFORMATION TO;LOCAL OFFICIALS PURSUANT TO SECTION 251807 OF. <br /> REPORT DATE CASEi THE TH <br /> • M M 0 Y Y uvTi: <br /> NAME OF IND AL FILING , �a b )4 � SI TURF •� <br /> a /t} <br /> m <br /> � flEPRES COMPANY OR AGE NAME <br /> NG ❑ OWNETVOPERATOR ❑ REGIONAL BOARD <br /> ALAGENCY ❑ OTHER <br /> 0 LOC �• �' <br /> O <br /> a <br /> ADDRESS I(�\/ /�'t I: /� ��„�/J� 1 ,I^, <br /> �5 1' • /VLY 1 BTREEf� "`( Y • CRV ✓��•�' • SATE IP <br /> NAME CONTACT <br /> PERSON PHONE <br /> Co a ❑ UNKNOWN Tim l. Serl g5g�7 S <br /> <y ADDRESS <br /> srATe ?Ob o <br /> v <br /> FACILITY LNAME(IF APPLICABLE) ��• III��bee4fffippeEEEEEFFF v` OPERATOR PHONE <br /> zf.(« Ski v[(u F fZ 2- ( <br /> 8 Ao-ss 7 S uij,� dl'1 �-a�� sqr Ta 4u(h 4 p <br /> mCROSS STREET/ _ s TYPE OF AREA COMMERCIAL❑INDUSTRIAL ❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> RESIDENTIAL Q OTHER 0 FARM.E Otl R <br /> LOCALAGENCY AGENCY NAME CONIACTPERSON PHONE <br /> PHONE S"G Se n tcAs3 �� P4HO r 6� <br /> M� R1/E�GIIONNA�L BOARD <br /> �q <br /> 19 NAME (' QUANTITY LOST(GALLONS) <br /> 1�31JNKNOWN <br /> y ❑ UNKNOWN <br /> i DATE DISCOVERED <br /> � HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS _ (� <br /> DATE DISMl CHARGE BEGAN Y Y ❑ TANK TEST � TANK REMOVAL ❑ OTHER <br /> GE <br /> METHOD USED TO STOP DISCHAR (CHECK ALL THAT APPLY) <br /> . 7'NKNOWN E:] REMOVECONTENTS ❑ REPLACETANK �Z•LOSE TANK <br /> M M D D Y V <br /> HAS DISCHARGE BEEN STOPPED T ❑ REPAIRTANK ❑ REPAIRPIPING ❑ CHANGEPROCEDURE <br /> p YES ❑ NO IFYES.DATE M M 01 DI Y Y ❑ OTHER <br /> SOURCE OF DISCHARGE TANKS ONLYrAPACITY MATERIAL CAUSE(S) <br /> ❑ TANKLEAK �BNKNOWN ID—GAL ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREFALURE <br /> c� ❑ PIPINGLEAK AGE YRS 12rSTEEL ❑ CORROSION e UNKNOWN <br /> O OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> wCHECKONEONLY <br /> L <br /> ❑ UNDETERMINED RT SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK ONE ONLY <br /> ¢� ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> VH �2rNO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> o ❑ CAP SITE(CD) ❑ EXCAVATE A DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> D+F <br /> CONTAINMENT BARRIER(CB) ❑ EXCAVATEA TREAT(En PUMPA TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> �� ❑ ❑ <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REOUIRED(NA) J EER(OT) <br /> 'ry• �� 6- <br /> ❑w/�`�OTH1 /v <br /> "' V <br /> Mac o51�1 <br />