Laserfiche WebLink
L�l <br />� <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />FOR LOCAL AGENCY USE ONLY <br />❑ YES NO REPORT BEEN FLED? El YES ❑ NO <br />HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br />REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF <br />THE HEALTH ANDpSAFFTY CODE i. /F <br />.C-C-i..c�_ 1�(,, {y _Z6 - <br />REPORTDATE �/,/y <br />6 •y / <br />CASES <br />SIGNED DATE. <br />Y <br />NAME OF INDIVIDUAL FLING REPORT <br />PHONE <br />SIGNATURE <br />W; - k,, K S <br />c 6P3V2o <br />REPRESENTING ❑ OWNEIVOPERATOR ❑ REGIONALBOARD <br />COMPANY OR AGENCY NAME <br />g <br />LOCAL AGENCY ❑ OTHER <br />Ll <br />,�XfL�'�JAIN �% � -Q <br />ADDRESS <br />et47d3+ sr.T.6& 9gUm <br />LH <br />w <br />NAME 11 <br />V I <br />C //��'�'��(,I�� <br />J ` LJ UNKNOWN <br />CONTACT PERSON PHONE <br />/N/� S <br /><y <br />ADDRESS 4 C {/�� �/J� �% �y /A' `` /(_ _ 31Z, / Z, (%�­ <br />J �LC,RYV 1 3lATE Y) U P <br />P z5— T, ".L- V o/✓��bLl' <br />FACILITY NAME (IF APPLICABLE) V <br />1 <br />OPERA R PHONE <br />4 <br />ADDRESS <br />m. <br />q <br />CROSS STREET n, <br />TYPE OF AREA OCOMMERCIAL ❑ INDUSTRIAL ❑ RURAL <br />TYPE OF BUSINESS O RETAIL FUEL STATION <br />9p <br />E::] RESIDENTIAL E::] OTHER <br />E:]FARM ❑ OTHER <br />i <br />LOCALAGENCV AGENCVNAME <br />v S — j&t4 <br />CONTACT PERSON <br />PHONE <br />aq )ilw3l/Zo <br />� <br />REGIONAL BOARD <br />� � � � � � <br />PHONE <br />( /) li/ S6 <br />m <br />(1) Mq NAME GUANTRV LOST (GALLONS) <br />A.I ❑ UNKNOWN <br />w <br />❑ UNKNOWN <br />i <br />w <br />DATE DISCOVERED <br />ON <br />HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MfNNRORNO ❑ NUISANCECON)ITIONS <br />M GA o YJ Y <br />❑ TANKTEST TANK REMOVAL OTHER <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br />w <br />1p( <br />Ml M o o r Y UNKNOWN <br />❑ REMOVECONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br />Q <br />❑ REPAIRTANK ❑ REPAIRPPNG ❑ CHANGE PROCEDURE <br />HIS DISCHARGE BEEN STOPPED? <br />p <br />❑ YES ❑ NO IFYES,DATE <br />❑ OTHER <br />M N o o r y <br />y <br />SOURCE OF DISCHARGE <br />TANKS ONL ITY MATERIAL <br />CAUSE(S) <br />❑ TANKLEAK >C UNKNOWN <br />GAL, ❑ FIBERGLASS <br />❑ OVERFILL ❑ RUPTUEFALURE <br />❑ PIPING LEAK <br />AGEYRS STEEL <br />❑ CORROSION ❑ UNKNOWN <br />f� <br />❑ OTHER <br />UNKNOWN ❑ OTHER <br />❑ SPILL ❑ OTHER _ <br />ww <br />a <br />CHECKONEONLV <br />O� <br />UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br />f, <br />CHECKONEONLY <br />s a <br />❑ SITE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) <br />vm <br />❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVALABLE TO PROCEED ❑ EVALUATINGCLEANLPALTERNATIVES <br />CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br />i <br />❑ CAP SITE (CD) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) <br />O CONTAINMENT BARRIER LOS) ❑ EXCAVATE& TREAT (ET) ❑ PUMP& TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br />F-1TREATMENTAT HOOKUP (HU) ❑ NO ACTION REQUIRED INA) ❑ OTHER(OT) <br />U ►1d9ALr o P. P-.( WV Y" G T K O� V4 Li h�.� Vim" 0 <br />A&e� Si QtScsS`n� :// NBe <br />a r`rG i h e, –/k e- v o-4t,%Y-e A - I.. � 2 X-F�- G1�- <br />