Laserfiche WebLink
9/- It I I b <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)! CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERG Y SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? Y ❑ No 1 HEREBY CERTIFY THAT 1 HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO <br /> Es THE <br /> ❑ YES NO DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET O THE BACK PAGE OF THIS FORM. <br /> a ° <br /> RCASE <br /> REPORT DATE DATE <br /> / M AMI od Y Y Y $ N <br /> PHONE SIGNATURE <br /> NAME OF INDIVIDUAL FILING REPORT �� ®® b�0`�) ���1' �� [� 4"e4�-�m ❑ COMPANY OR AGENCY NAME <br /> ❑ REPRESENT G ❑ OWNER/OPERATOR REGIONALBOARD may ` <br /> w J` <br /> ~ OTHER _ <br /> Q LOCALAGENCY ❑ <br /> Lij <br /> cc <br /> a <br /> ADDRESS 7 e,ooyy <br /> P. o, 'zCITY STATE ZIP <br /> NAME <br /> STREET PHONE <br /> / <br /> CONTACT PERSON `� <br /> w <br /> 1 ❑ UNKNOWN : <br /> m6"PAX <br /> L� <br /> zQ <br /> Oa ADr " $$ 5- l s <br /> Lo <br /> at Q• CITY STATE 21P <br /> 2 STREET PHONE <br /> OPERATOR <br /> FACILITY NAME(IF APPLICABLE) 1 <br /> ° , <br /> a ADDRESS <br /> ('yam Fli "✓��� COUNTY ZIP <br /> 0 CITY CJ `� t STREET <br /> w <br /> �= CROSS STREET <br /> N <br /> AGENCY NAME <br /> CONTACT PERSON j/� , ,�P^H�O/N�)E / <br /> LOCAL AGENCY " V � '3'y <br /> / <br /> w U � C PHONE <br /> w w REGIONAL BOARD <br /> J� <br /> a QUANTITY LOST(GALLONS) <br /> NAME <br /> UNKNOWN <br /> w 0 <br /> z (p) C Et <br /> UNKNOWN <br /> ❑ SUBSURFACE MONITORING ❑ N ISANCE CONDITION <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ INV TORY CONTROL �( <br /> LIS /{/1� 3 ❑ TANK TEST ANK REMOVAL OTHER Ye <br /> w 1 MI MI °� YI y METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APP ) <br /> a <br /> m DATE DISCHARGE BEGAN ❑ <br /> ❑REPAIR PIPING <br /> Eel UNKNOWN REMOVE CONTENTS LOSE TANK&REMOVE <br /> M M D D YLu y ❑REPAIR TANK ❑C OSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> 0 HAS DISCH E BEEN STOPPED? <br /> O L I J ❑REPLACE TANK OTHER <br /> Ln YES ❑ NO IF YES,DATE <br /> SOURCE OF DISCHARGE CAUSES) <br /> 5��ALEAK ❑ UNKNOWN F--] OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> co c ❑ UNKNOWN ❑ OTHER <br /> a ❑ CORROSION <br /> ON v cr <br /> PIPING LEAK OTHER <br /> w w CHECK ONE ONLY <br /> U)a <br /> v ❑ UNDETERMINED dSOIL ONLY ❑ GROUNDWATER E] DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFEC <br /> CHECK ONE ONLY POLLUTION CHARACTERIZATION <br /> z NO ACTION TAKEN m ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ <br /> LL! PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS r <br /> Q Il ❑ LEAK BEING CONFIRMED ❑ <br /> Om ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) E:] CLEANUP UNDERWAY <br /> ❑ REMEDIATION PLAN REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ <br /> (SEE BOCK FOR UFT"°S) PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> a zCAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ <br /> w F ❑ O ACTION REQUIRED(NA) ❑ TREATME T AT HOOKUP(HU) ❑ VENT SOIL(VS) (^ <br /> 0 El ACTION BARRIER(CB) ElLLJ ` <br /> ❑ oya <br /> VACUUM EXTRACT(VE) OTHER(OT) sS ! <br /> zt4lt 4,00ltlJJ <br /> z - -� <br /> w <br /> 2 �a <br /> O0 <br /> ^e � I HSC OS( 0 <br />