Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY< <br /> YES NO REPORT BEEN FILED 7 DYES Q NO RHEREBY CERTIFY THAT I AM GOVERNMENT NAND THAT I <br /> EPORTED THIS FORMATION TO DESIGNATEDLOCALOF ICIALS PURSUANT TOO SECTION 251807AOF <br /> REPORT DATE CASE$ THE HEALTH AND SAFTY CODE r <br /> 9 I P[fJ <br /> M 1 M o �D �v v SGNED D#7 <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> S pSvV:F-L V9J^,3Oo GS A - <br /> R PRESENTING O OWNELVOPERATOR 0 GIONAL SO Rn COMPANY OR AGENCY NAME S <br /> p :LOCAL AGENCY OTHER N <br /> ADDRESS /� R '�/ <br /> I o I V o T SIRE CRr L V $FATE / IP <br /> NAME 5 _/_ __oL fs t ONTACT PERSON PHONE <br /> ❑ UNKNOWN <br /> a ADDRESS ///� I- p K4r/. - <br /> ¢ 2 D BEET/ W Vl 15{.i � CT' el STATE <br /> FACILITY NAME(IF APPLICABLE) 0� OPERATOR PHONE P <br /> (INi J o <br /> ADDRESS '//J, <br /> I� V//'�/ �TREW��SL • / <br /> �J CITY CWMfY P <br /> CROSS STREET TYPE OF AREA ❑COMME L OINDUSTRIAL RURAL TYPE OF BUSINESS O RETAIL FUEL TATION <br /> Q RESIDENTIAL HER Q FARM 0 OTHER <br /> y LOCALAGENCV pOF,(��I�AyF of N Co, CONTACTPERSON PHONE <br /> w iG a N ,�J r'Ils7C a��.+lJ (�o y6 g ;o <br /> REGIONAL BOARD <br /> o PHONE <br /> C--VR azac R 9216 361-:5100 <br /> w (1) NAME QUANTITY LOST(GALLON!) <br /> 501 ✓ e-- <br /> U KNOWN <br /> (2) <br /> D U NOWN <br /> D� <br /> DATE <br /> DISCOVERED D D yV��yv'R1 HOW DISCOVERED 0 INVENTORY CONTROL SUBSURFACE MONITORING <br /> NUISANCE CON ITgNS <br /> TANK TEST TANK REMOVAL OTHERr <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M D D y v NrUNKNOWN REMOVE CONTENTS REPLACE TANK CLOSE TANK <br /> Q HAS DISCHARGE BEEN STOPPED 7 REPAIR TANK REPAIRPIPWG CHANGEPROCEDURE <br /> p YES �NO IFYES,DATE ® OTHER <br /> M M D DI VI v <br /> uU SOURCE OF DISCHARGE TANKS ONLYACAPACITY MATERIAL CAUSES) <br /> 3 Q TANKLEAK MUNKNOWN GAL, Q FIBERGLASS O OVERFILL O RUPTURFA ALURE <br /> PIPING LEAK AGE YRS STEEL CORROSION EK UNKNOWN <br /> Q OTHER UNKNOWN OTHER O SPILL 0 OTHER <br /> CHECKO ONLY <br /> UNDETERMINED Q SOILONLY O GROUNDWATER O DRINKINGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> F, CHECKO ONLY <br /> z� <br /> ca SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) 0 CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETEDOR UNNECESSARY) <br /> VN 0 NOACTIONTAKEN O POSTCLEANUPMONITORINGINPROGRESS NO FUNDS AVAILABLE TO PROCEED D EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 0 0 CAP SITE(CD) O EXCAVATE d DISPOSE(ED) REMOVE FREE PRODUCT(FP) D ENHANCED BIO DEGRADA (m <br /> CONTAINMENT SARRIER(CB) EXCAVATE&TREAT(ET) PB TREAT GROUNDWATER(GT) REPLACE SUPPLY IRS) <br /> TREATMENT AT HOOKUP(HU) 0 NO ACTION REQUIRED INA) OTHER(OT) <br /> K [L / pr��� sidylsf o�✓ 8 Z g�i 0,oi/s,7ER e <br /> � ��• Gil2`�P�2 �5,� �isSeSsm?M"f' l�,oG 6�. !� u�� deo <br /> rXp °$¢M/ha- Ile, i1-4cfurG lr rld 6X�p,H�- r,G CON7ANaln1 L} oN <br /> $ As r ur-cdl +Ae. Yb rc41� In l 2 Q 'e�.uc <br />