Laserfiche WebLink
• 7.)_ tc4 0 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> HAS STATE OFFICE OF ETHE <br /> MERGENCY SERVICE FOR LOCAL AGENCY <br /> 'USE ONLY <br /> EMERGENCY �I REPORT BEEN FILED 7 NO 1 HEREBY CERTIFYTHAT 1 HAE DISTRIBUTED <br /> ISTTRUBTION SHEETONON THE BACK <br /> pp O F H ORO <br /> �j E] YES p;STRIBU710N �. /.. <br /> E] YES J�J NO z-� <br /> CASE X ✓'` ''Z- > .;�' <br /> REPORT DATE SIGNED <br /> G� '� - <br /> `//J, PHONE SIGN RE __- <br /> OM <br /> NAME OFIN�DUALFILI GRE,PO9RT �� ) <br /> > //�,v Aq� AL BOARD COMPANY OR AGENCY NAME /�� <br /> m REGIONAL /`O. � �si <br /> o REPRESENTING ❑ OWNER/OPERATOR ❑ C� <br /> OTHER Z-0I <br /> o OCAL AGENCY ❑ F � `�� �) / _ <br /> J r,D� <br /> T ////���� STATE ZIP <br /> ADDRESS <br /> �/` j• /`� �' / PHONE <br /> STREET CONTACT PERSON/ f-0 <br /> w NAME (^� `� �1/�� <br /> ��v� ❑ UNKNOWN /L, AID <br /> Z¢ IP <br /> a as ADDRESS V�� STATE <br /> �)� DQ/� Dm PHONE <br /> w �OO 1 /- STREET l?j$ <br /> ¢ OPERATOR ^__,^ p��26� <br /> FACILITY NAME(IF APPLICABLE) .— ��+/ �J (!� 7 <br /> Z �l54 <br /> ^ � COUNTY 21P <br /> ADDRESS /!��' CITY <br /> OO -7P-&/ ©� STREET <br /> w <br /> CROSS STREET <br /> Y^ck�A O�3 PHONE <br /> AGENCY NAME CONTACT PERSON <br /> O <br /> LOCAL <br /> /AGENCY <br /> �� <br /> PHONE <br /> z <br /> w oz w REGIONAL BOARD <br /> a< QUANTITY LOST(GALLONS) <br /> NAME UNKNOWN <br /> 0 <br /> w <br /> ❑ UNKNOWN !VI <br /> m° (2) <br /> w? ❑ ❑ NUISANCE CONDITIONSv <br /> ITO <br /> SUBSURFACE MONRING <br /> HOW DISCOVERED ❑ INVENTORY CONTROL a <br /> DATE DISCOVERED d TANK REMOVAL ❑ OTHER <br /> z 2f ❑ TANK TEST <br /> w L/M� lir <br /> M p DI Y METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> t CLOSE TANK 8 REMOVE ❑REPAIR PIPING <br /> a DATE DISCHARGE BEGAN ❑REMOVE CONTENTS d <br /> m UNKNOWN <br /> a p v v E]REPAIR TANK CLOSE TANK TANK 8 FILL IN PLACE ❑CHANGE PROCEDURE <br /> W M M D <br /> 0 HAS DISCHARGE BEEN STOPPED 7 ❑REPLACE TANK E]OTHER <br /> 11YES ❑ NO IF YES,DATE M MI D <br /> o p CAUSE(S)Y <br /> ❑ OVERFILL eUU* <br /> TURE/FAILURE SPILL <br /> � SOURCE OF DISCHARGEit c ❑ TANK LEAK UNKNOWN OTHERM a CORROSIONNOWN <br /> 0 v ❑ PIPING LEAK ❑ OTHER <br /> w w CHECK ONE ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> v ❑ UNDETERMINED ❑ SOIL ONLY <br /> POLLUTION CHARACTERIZATION <br /> CHECK ONE ONLY PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ <br /> z rn ❑ ❑ ❑ POST CLEANUP MONITORING IN PROGRESS <br /> NO ACTION TAKEN <br /> w PE] PRELIMINARY SITE ASSESSMENT UNDERWAY CLEANUP UNDERWAY <br /> Q a ❑ LEAK BEING CONFIRMED <br /> U w ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) I <br /> ❑ REMEDIATION PLAN REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> ❑ <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 8 DISPOSE(ED) ❑ PUMP 8 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ISEE BACK FM DEfALS) ❑ EXCAVATE B TREAT(ET) ❑ <br /> a z ❑ CAP SITE(CD) VENT SOIL(VS) <br /> 5 0 ❑CONTAINMENT BARRIER(CB) ❑� <br /> NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ <br /> Lu <br /> ¢< ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) rw AD_ 1 Q'f?C�a Q <br /> �t�5/�oN�r�B /a'a''`j�' 'A��Tim F i41�t J lip, fr�/_ <br /> Z .,ti ALS <br /> r✓f �o ixllr14>4 <br /> 0E ` Irl !' / 1�/Y'/ N30 0.51BI9G) <br />