UAR/PROP 65_PRE 2019 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY ❑ YES NO REPORT BEEN FLED? DYES ❑ NOI HEREBY CERTIFY THAT I AM rVE REPORTED THIS NFORMATIONATO LOCAL OFFICIALS PURSUANT TOTED GOVERNMENT E E AND THAT I A SECTION 251807 OF REPDRTDATE CASE* THE HEALTHAND SAFTY CODE - �/u 1 -I DI gYJ G 1 v SIGNED -- - — DATE NAME OFNDIVIDUAL FLING REPORT PHONE SIGNATURE W i UAm vc� —N G✓zGlr y2 REPRESENTING ❑ OWNEWOPEMTOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME p ER LOCALAGENCY ❑ OTHER a ADDRESS SPATE ZIP NAME / / ffVi�CONTACT PERSIXJ PHONE is A2 / DN ,KNOWN,/ .2 efPf�s y ADDRESS / CRY / 9Si-✓ 21P FACILITY NAME(F APPLICABLE) OPERATOR PHONE ADDRESS O e77-1 op y CROSSSTREET _ TYPE OF AREA [:]COMMERCIAL❑INDUSTRIAL❑RURAL TY OF BUSINESS ❑ RETAIL FUEL STATION U� D N ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE w O N IN (zoVzo REGIONAL BOARD� ^ PHONE (1) NAME QUANTITY LOST(GALLONS) o T L UNKNOWN — ❑ UNKNOWN i DATE DI VER�YD HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS M V o D S Y ❑ TANK TEST TANK REMOVAL ❑ OTHER DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) w Ml M DI DI Yl Yl UNKNOWN REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK HAS DISCHARGE BEEN STOPPED? ❑ REPAIRTANK ❑ REPAIRPPNG O CHANGE PROCEDURE ❑ YES ❑ NO FYES.DATE M M DI o YJ v ❑ OTHER ul SOURCE OF DISCHARGE TANKS ONLYCAPACITY MATERIAL CAUSE(S) ❑ TANKLEAK X UNKNOWN /S� Soo GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ PIPING LEAK AGE YRS ❑ STEEL ❑ CORROSION UNKNOWN ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER w� CHECK ONE ONLY UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) F, CHECKONEONLY ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SKIINED OFF(CLEANUP COMPLETED OR UNNECESSARY) ❑ NDACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) ❑ CAP SITE(CD) ❑ EXCAVATE b DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE B TREAT(ET) ❑ PUMPB TREATGROUNDWATER(On ❑ REPLACE SUPPLY(RS) Q TREATMENT AT HOOKUP(YIN) O NO ACTION REQUIRED INA) OTHER(OT) itts' S/ /�SS�SSvK�i/w W jLL ✓��uLi /^7o Rlw vLoL e-e- o �,o4 2 K �Zrn 7 o G ti I✓7f�M nv erl I-5 r2el u-i/z e-c4 6y d-L.e. a Pro p r^Ae, NAIG�(AV)