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 /> REPORT BEEN FILED? I HEREBY CERTIFY.THAT 1 AM A DESIGNATED GOVERNMENT.EMPLOYEE AND THAT 1 HAVE <br /> ❑ YES ] NO ❑YES ND REPORTED THIS INFORMATION.TO LOCAL QFFICIALS PURSUANT TO SECTION 25180.7 OF <br /> REPORT DATE CASE* THEHEAL ANO SAFTY _ .,... i <br /> 1f Xn `/�� <br /> 1 M 1 o p Y 1 v vSK3NED DATE <br /> NAME OF INDIVIDUAL FILING REPORT C' PHONE //U0L{; SIGNATURE / <br /> T l t i fk K . SNgve c ) 7 '>7 210 64— <br /> REPRESENTING <br /> wREPRESENTING ❑ OWNER/OPERANR Fj REGIONALBOARD COMPANY OR AGENCY NAME R Loc1 /�GnI <br /> G <br /> S LOCALAGENCY ❑ OTHER 14w �/Or3-�,/,t( 4-C� (J 'YI��TH ���s?FJ <br /> ADDRESS R <br /> 9t O t s CRY &TATE <br /> NAME �± (� (��+/-7 C�yON/TACTPERSON �y,p PHONE 9 its y <br /> of- �y-J7tlo io UNKNOWN JYL���I �J �/J/�0 ��' O /` <br /> ¢<y <br /> ADDRESS W/,I <br /> J cm erATE ar <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> yie F ar✓/c�� V�919f�6-4� <br /> s ADDRESS aa X 2/A/t J(�j 9 <br /> A V ( O BTREET r'V `i / r /AI <br /> CT <br /> ap <br /> yCROSS STREET TYPE OF AREA ❑COMMERCIAL❑INDUSTRIAL❑RURAL TYPEOFBUSINESS a RETAILFUELSTATION <br /> ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> g LOCALAGENCY AGENCY NAME DI� CONTACTPERSON PHONE <br /> S o UiNL4CX&tl c 6�-3Sf2a <br /> ;y REGIONAL 80A� /Z� 60 ft) <br /> / f70 d <br /> NAME QUANTITY LOST(GALLONS) <br /> 6 1AN K 0 J ❑ UNKNOWN <br /> 90 (2) <br /> w- ❑ UNKNOWN <br /> i DATEDISCOVERED HDWOISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCECONDRIONS <br /> DM M o o <br /> I'll <br /> ' Y ❑ TANI(TEST TANK REMOVAL ❑ OTHER <br /> 4 DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> ML <br /> M o o y y UNKNOWN ❑ REMOVECONTENTS ❑ REPLACETANK CLOSETANK <br /> HAS DISCHARGE BEEN STOPPED? ❑ REPAIRTANK ❑ REPAIRPIPING ❑ CHANGEPROCEDURE <br /> p ❑ YES ❑ NO IFYES.DATE M M o ID y Y ❑ OTHER <br /> yp SOURCE OF DISCHARGE TANKS ONLYCAPAC�I/TY MATERIAL CAUSE(S) <br /> E::] TANKLEAK '1 UNKNOWN � y GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE11FAILURE <br /> c ❑ PIPINGLEAK AGE111,Ak- YRS STEEL ❑ CORROSION X UNKNOWN <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> ywy CHECK ONE ONLY <br /> g� UNDETERMINED ❑ SOILONLY ❑ GROUNDWATER ❑ DRINKWGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> z CHECK ONE ONLV <br /> w <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS [ <br /> SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> UN ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATINGCLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> az ❑ CAPSITE(CD) ❑ EXCAVATE B DISPOSE(10 ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(In <br /> i ❑ CONTAINMENT BARRIER(08) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY IRS) <br /> ❑ TREATMENT AT HOOKUP(HU) ❑ NOACTIONREOUIRED(NA) ❑ OTHER(On <br /> w YZ�e h a f1 <br /> r2fu Aeri bV Y%e� AbOrVIO rtes XPi <br /> mwm(w <br />