Laserfiche WebLink
v 0 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> VE <br /> F7 YES NO REPORT BEEN FILED? [::]YES ❑ NO REPORTED THIS NFORMATIONI HEREBY CERTIFY THAT I AM ATO LOCATOFFOALSED N PURSUANT TOMENT E SECTION 251807E AND THAT I AOF <br /> REPORT DATECASEt THE HEALTH AND SAFTY CODE ' <br /> M L� 9.1 ✓ Y p y SIGNED // DATE <br /> NAME OF INDIVIDUAL FILING REPORT i5( PHONE SIGNATURE J(/('GL11�'— �C <br /> int' - ,u P- Srt ArV (20 <br /> o REPRESENTING ❑ OWNEIVOPERATOR ❑ RE IONALBOARD COMPANY OR AGEN NAME ) \ <br /> o LOCALAGENCY ❑ OTHER S,g/r� �.� (� 1/a c A-` <br /> 6 <br /> ADDRESSSS/ /�,//+� T/,�� <br /> ! V / TRE �7 CrtY S//�- , SfATE ZIP <br /> NA E ...{- r C /r� /r_ CONTACT PERSON /J �� /P'HOgNE A <br /> zimQO l C J V GI�7O a ❑ UNKNOWN �.V(A y / l!L L <br /> <y ADDRESS / L C C/ �/�_ -/ /' <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS� a2ol I a Er GllffS�in/�ir��v 47-, S7/.e.-v- CA— <br /> CROSS STREET TYPE OF AREA OCOMMERCIAL WINDUSTRAL RURAL TYPE OF BUSINESS O RETAIL FUEL STATION <br /> G ❑RESIDENTIAL ❑OTHER O FARMK OTHER <br /> % LOCALAGENCY AGENCY NAME OONTACTPERSON PHONE <br /> =w Spiv u <br /> REGIONAL BOARD PHONE <br /> v 2w ( > 36i-syoo <br /> (7) NAME QUANTITY LOST(GALLONS) <br /> 7z UNKNOWN <br /> 0 (�) <br /> Xy L ew ® UNKNOWN <br /> k <br /> DATEDISCOVEITED WDIVEp, n HO <br /> I� TVENTOROVA SOL E::] OTHERRFACEMONITORWG E::] NUISANCE CONDITIONS <br /> M :5.1001 D gY U% V ❑ <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M o o y y I� UNKNOWN ❑ REMOVECONTENTS ❑ REPLACETANK CLOSETANK <br /> HAS DISCHARGE BEEN STOPPED 7 ❑ REPAIRTANK ❑ REPAIR PIPING CHANCE PROCEDURE <br /> S YES ❑ NO IFYES,DATE M /.16.1 V v v ❑ OTHER <br /> I� SOURCE OF DISCHARGE TANKS ONLYrAPACITV MATERIAL CAUSE(S) <br /> O ❑ TANKLEAK UNKNOWN /2�GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> ❑ PIPINGLEAK AGE YRS STEEL ❑ CORROSION ) UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN ((❑ OTHER ❑ SPILL O OTHER <br /> ww CHECKONEONLY <br /> Dj� UNDETERMINED ❑ SOILONLY O GROUNDWATER O DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY <br /> 2y <br /> as SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESSO SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> Uy ❑ NOACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS O NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 3 ❑ CAP SITE(CD) ❑ EXCAVATE&DISPoSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> a ❑ CONTAINMENT BARRIER(CS) ❑ EXCAVATE TREAT(ET) ❑ PUMP&TREAT GRODU�NDW+ATER(Gn REPLACE SUPPLY IRS) <br /> -1TREATMENT AT HOOKUP(HU) ❑ NOACTIONREOUIRED(NA) OTHER(On r(.�DW,.-6 coMMFzW7f <br /> _ZNFaRMgD GW/lCr Yy- rYSP.c�f�t <br /> z Qsid /0,0.5 b/P S/ aSSPssfyw.�- ��'GL 6t iieta/ �a <br /> a(e fe2rrl�He c/e+er✓lz�a/ q� �e o2i�o i✓z �?�fes. a co,j-rAtw -M A-F/c v <br /> HSCM(4%„ <br />