Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT <br /> EMERGENCY / HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> YES 'L—✓J NO REPORTBEENFILEDI OYES No I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT.EMPLOYEE AND THAT I HAVE <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25160,7 OF <br /> REPORTDATECASEt <br /> 9 (]�j J <br /> OM 3.1 O / " Y �v MNEV I /DATE <br /> NAME OF INDIVIDUAL FILING REPOR,1, E SIGNATU <br /> m <br /> 0 REPRESE NO O OWNEFVOPERATOR D REGIONALBOARD COMPANY OR AGENCY NAME r/A� �{. <br /> If LOCAL AGENCY ❑ OTHER S ,44& C Q �(//,Sf/`/ y <br /> ADORFCC ^�^ �.^ <br /> l/ /H/s ATE zP <br /> NAME pp (/ CONT/�AC�T PERSON�yT,.,�, ,. �,,• PHONE <br /> PQ h C++ rum/ O UNIRJOWN dam! 1 w'K�l .r (�9)INS 5oW <br /> a ADDRESS <br /> 0? ] 50 t. �REMon � P'0' S'�ocKdvr. C/� �5aa � <br /> 111 J? CRY WATE P <br /> FACLITY NAME IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS e' p4'H--p-� I rG� r✓�Ci (��)'�f6X -GGH6 <br /> a 1 S o S46 K4e,-, 15aoir <br /> IB CROSS STREET TYPE OF AREA COMMERCIAL O INDUSTRIAL O RURAL TYPEOFBUSINESS O RETAIL FUEL STATION <br /> O RESIDENTIAL O OTHER Q FARM Q OTHER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> ~q <br /> w REGIONAL BOARD <br /> PHONE <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> 13 I e O UNKNOWN <br /> (2) <br /> O UNKNOWN <br /> i DRAT/REDISCOVERED �j� �X]. HOWryDISCCOVERED INVENTORYCONTROL O SUBSURFACE MONITORING Q NUISANCE CONDITIONS <br /> `�M �M ODI <br /> �L/D VY �v Eo"'TANK TEST O TANK REMOVAL O OTHER <br /> DATE DISCHARGE BEGAN as 7 METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w 6M ` . 3o OD Y v UNKNOWN REMOVE CONTENTS O REPLACETANK O CLOSETANK <br /> NASD ES ❑SE ESTOPPED?ATE 0.M 7M ao ao ?Z �v �THER t�&'f REPAIRTANK �REPAIRPIPNG O CHANGE PROCEDURE <br /> IF YES. UY /J� 1/494-'r <br /> ISI SOURCE OF DISCHARGE TANKS ONUWCAPACITY MATERIAL CAUSE(S) <br /> 3 O TANK LEAK O UNKNOWN /DfQQl GAL. O FIBERGLASS O OVERFILL RUPTURE/fAILURE <br /> PIPING LEAK AGE 3a, YRS STEEL O CORROSION O UNKNOWN <br /> O OTHER O UNKNOWN O OTHER O SPILL1d OTHER JD_1L , Cf <br /> n. <br /> CHECKONE NLV <br /> c3� UNDETERMINED O SOILONLV O GROUNDWATER O DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKIXJ�,ONLY <br /> �Q/SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) O CLEANUP IN PROGRESS O SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> It <br /> 80 O NOACTIONTAKEN O POST CLEANUP MONITORING IN PROGRESS O NO FUNDS AVAILABLE TO PROCEED O EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 99 O CAP SITE(CD) O EXCAVATE&DISPOSE(ED) O REMOVE FREE PRODUCT(FP) O ENHANCED BIO DEGRADATION(IT) <br /> ,W3., ❑ CONTAINMENT BARRIER(CB) O EXCAVATE&TREAT(ET) O PUMP&TREAT GROUNDWATER(GT) O REPLACE SUPPLY(RS) <br /> TREATMENT AT HOOKUP(HU) O NO ACTION REQUIRED INA) O OTHER(OT) <br /> 1Q,o009a,� d;esef <br /> T pItsse u se -y-eSf- ate. -71P I/,?7 <br /> z r a Ss "I"i, <br />