UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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1f 0ecc;ra4'f. P1rl0►r VA 9/—'u 3 1 UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) !CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY IS RVIC FOR LOCAL AGENCY USE ONLY REPORT B€EN FILED? I HEREBY CERTIFY THAT 1 AM A OESIGNATE13 GOVERNMENT EMPLOYEE AND THAT I HAVE ❑ YES No ❑Yt s REPORTED THIS INFORMATION TO LOCAL OFFICIALS:PURSUANT. . SECTION 251 OF THE HEALTH AND SAFTY CODE. REPORT DATE CASES t}m m Tee- � ,F f� �nSIGNEb RAT qY v PHONE SIG TU NUE OF INDIVIDUAL ILING REPORT ) ,"4 g , r b 8 �.� V�Dje 1 Y y m ❑ COMPANY OR AGENCY NAME w REPRESS WG ❑ OWNERIOPERATOR REGIONALBOARD O LOCAL AGENCY ❑ OTHER / a gAz 06 ADDRESS hh C.� tin �✓ � ��" �� 1 ✓1 � CITY 9TA� ZIP -1 �, ` STREEr PHONE n CONTACT PERSON q"yo�y� J NAME 1� B��rr{wI l � UNKNOWN ' Keller co �Fc dl �J/ I Z 6zfs�J Z< , GI / Qa ADDRESS f_ Q <y to 'U� It3 ! ✓ STATE ZIP w "� o MY R STREET PHONE OPERATOR ,f / FACILITY NAME(IF APPLICABLE) f'�� ,ry ` U- �((�b z 6 f� �', �L J b+�-1 W " N 1 rte'' F� ( � ;I . � Z0 ADDRESS t 4V n be� -2+ - 1 C� r (�� C TlC-� coSHrr nP � srREEx TYPE OF BUSYNESS RETAIL FUEL STATION CROSS STREET I,, TYPE OF AREA ❑COMMERCIAL INDUSTRIAL❑RURAL ❑ ��pj� ` y� T(� a RESIDENTIAL ❑OTHER ❑ FARM OTHER fV1 Lno) CONTACT PERSON PHONE LO AL AGENCY AGENCY NAME14 D `` z PHONE w w REGNA BO CL } 4 QUANTITY LOST(GALLONS) NAME (1) + UNKNOWN c5 0 (2) ❑ UNKNOWN HOW DISC VERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS � DATE DISCOVERED /� ❑ 'Zi y5 TANK TEST ❑ TANK REMOVAL OTHER Co �o fl VY Y METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLYy DATE DISCHARGE BEGAN UNKNOWN �❑ REMOVE CONTENTS ❑ REPLACE TANK. CLOSE TANK w M m o o Y v ❑ REPAIRTANK ❑ REPAIRPIPING ❑ CHANGE PROCEDURE n HAS DIS ARGE BEEN STOPPED 7 Q c YES [❑ NO IFYES,DATE M �M ZQ 1, U v S Y ❑ OTHER Q TANKS ONLYICAPACITY MATERIAL CAUSE(S) N SOURCE OF DISCHARGE ��^''}� 3 ❑ TANK LEAK UNKNOWN [_/ GAL. n F}9ERGLASS ❑ OVERFILL PTURE FAILURE 6 �{wsy/STEEL fl CORROSION UNKNOWN ❑ PIPINGLEAK AGE YRS ❑ OTHER UNKNOWN LD OTHER ❑ SPILL ❑ OTHER w w CHECK ONE ONLY UEL} [:2 UNDETERMINED ❑ SOIL ONLY GROUNDWATER DRINKING WATER - (CHECK ONLY 1F WATER WELLS HAVE ACTUALLY BEEN AFFECTED) �A CHECK ONE ONLY ❑ SITE INVESTIGATION IN PROGRESS(D FINING EXTENT OF PROBLEM) ❑ CLEANUP(AS PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) v ❑ NO ACTION TAKEN [_] POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) REMOVE FREE PRODUCT IFP) ❑ ENHANCED BID DEGRADATION(IT) 471 ❑ CAP SITE(CD)ENT &DISPOSE(ED) ❑ Li ❑ CONTAINMENT BARRIER(OB) ❑ EXCAVATE&TREAT(FT) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACESUPPLY(RS) ❑ TREATMENT AT HOOKUP(HUy NO ACTION REQUIRED(NA) ❑ OTHER(OT) ❑ rri z w HSC 05(4187)