Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY - HAS STATE OFFICE OF EMERGENCY SER 3 'FOR LOCALAGENCYUSE ONLY <br /> VES NO <br /> REPORT BEEN FILED 7 VES NO I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> � <br /> DIST UTION SH N ON THE INSTRUC�JIOI�SHEEf ON THE BACK PAGE OF HIS F <br /> REPORT DATE DATE CASE+1- �./ ,t„(' �.. 11; <br /> M D M L Y �EC <br /> SIGNED (�. DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SI AT)RE <br /> w REPRESENTING OWNEq/OPERATOq Q REGIONALBOARD COMPANY OR AGENCY NAME <br /> S �OCAL AGENCY Q OTHER S,�,J . c/0, pig 69b ^ <br /> ADDRESS V • O / / ` C4 STATE V\' <br /> J N ME CONTACT PERSON PHONE <br /> vi , I] UNKNOWN <br /> zQ <br /> yn ADDRESS <br /> ¢ <br /> 3333 TREEIRcq <br /> FACILITY NAME(IF APPLICABLE) q vv OPERATOR PHONE O <br /> a ADDRESSc,& <br /> > <br /> U <br /> 9TREEf LRV LOU 21P <br /> y CROSS STREET <br /> V0.aA <br /> L A AGENCY AGENCY NAME CONTACTPERSON PHONE <br /> =y wvY4P- <br /> w REGION ARD PHONE <br /> 2 r, a C-8 6. <br /> y (1) NAME JQUANTITY LOST(GALLO S) <br /> 0 <br /> J UNKNOWN <br /> m O° (2) f <br /> NZ <br /> 6 UNKNOWN <br /> i DATE DISCOVEREDHOW DISCOVERED INVENTORY CONTROL O SUBSURFACE MONITORING O NUISANCE CONDITIONS <br /> OM My 'Y TANK TEST TANK REMOVAL OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT AP LY) <br /> a <br /> UNKNOWN REMOVE CONTENTS ®CLOSE TANK 6 REMOVE PAIR PIPING <br /> W <br /> M M D D Y Y <br /> HAS DISCHARGE BEEN STOPPED? O REPAIR TANK CLOSE TANK S FILL IN PLACE E�]CHANGE PROCEDURE <br /> oEoVES ❑ NO IF YES.DATE .1 M DI d Y V REPLACE TANK OOTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢jTANK LEAK UNKNOWN OVERFILL TURE/FAILURE SPILL <br /> 0, PIPING LEAK OTHER E:] CORROSION NKNOWN 0 OTHER <br /> y w CHECK,9KEONLY <br /> O UNDETERMINED SOIL ONLY GROUNDWATER [:] DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> jy LEAK BEING CONFIRMED F7 PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> O F-� REMEDIATION PLAN O CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) F--j EXCAVATE&DISPOSE(ED) 0 REMOVE FREE PRODUCT(FP) ENHANCED BID DEGRADATION(IT) <br /> JewMswoETUE) <br /> op CAPSITE(CD) ❑ EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY IRS) <br /> wr <br /> a � CONTAINMENT BARRIER(CB) E] NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> �T] VACUUM EXTRACT(VE) F-1 OTHER(OT) <br /> �Gu J� '�`.7� larl v�-.t toi J Gt/ �la4cG 1 d1ft -+-4 .f <br /> 2 <br /> U <br /> HSL Ds l%`r% <br />