Laserfiche WebLink
0 0 1 ( 41 riD <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCYHAS STATE OFFICE OF EMERG CY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES NO ES NO <br /> REPORT BEEN FILED Y ❑ <br /> 1 HEREBY CERTIFYTHA71 HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTION SHOWSTION SHEET ON SACK PAGE OF THIS FORM <br /> REPORT DATE (/%�� CASE at <br /> J ( Y -.i w <br /> DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> J <br /> m <br /> 4i 6�,,OL, <br /> w REPRESING F-1 OWNER/OPERATOR F__] REGIONAL BOARD COMPANY OR AGENCY NAME <br /> pLOCAL AGENCY ❑ OTHER <br /> cr ADDRE S .L, lI.JJ <br /> 6, ooh S�©G� 09 ��d6 <br /> STREET CITY STATE ZIP <br /> J NAMECONT CT PERSON PHONE <br /> z UNKNOWN <br /> Q <br /> o< <br /> ADDRESS <br /> Lu <br /> cr <br /> Cl-s o f � <br /> STgEETSTATE z <br /> PHONE <br /> FACILI�AM�APPLI OPERATOR <br /> O <br /> c ADDRESS <br /> STREET <br /> COUNTYP <br /> ytz <br /> CROSS STREET ZIP <br /> LOCAL AGENCYAGENCY NAME CONTACT PERSON PHONE <br /> zy <br /> ~w pHs c ) <br /> w U <br /> w w REGIONAOARD ` PHONE <br /> a a (1K)` � y , <br /> J ( ) <br /> y (1) NAME QUANTITY LOST(GALLO ) <br /> U O �Q <br /> a� �G UNKNOWN <br /> CD z <br /> UNKNOWN <br /> z DATE DISCOVERED DISCOVERED ❑[ INV NTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w <br /> w MI MI pI pl r <br /> J'�bOW <br /> ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> m DATE DISCHARGE BEGAN METHO SED TO STOP DISCHi (CHECK ALL THAT APPLY) <br /> a <br /> UNKNOWN REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> Lu M M D D Y Y <br /> Q HAS DIS RGE BEEN STOPPED? E::]REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> U / /y� /J <br /> o YES ❑ NO IF YES,DATE F MI �MI / p D /Y / v ❑REPLACE TANK ❑ OTHER <br /> La SOURCE DISCHARGE CAUSES) <br /> w <br /> cro TANK LEAK ❑ UNKNOWN OVERFILL ❑ RUPTURE/FAILURE E:] SPILL <br /> c v ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> w wa CHECK ONE ONLY <br /> U ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> z cn ❑ NO ACTION TAKEN PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w <br /> cr <br /> Cc <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS / <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY ) <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J (SEE HACK FOR MA") <br /> az F_]o O CAP SITE(CD) F-1EXCAVATE&TREAT(ET) E:] PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> uj a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> cr <br /> ❑ VA❑ CUUM EXTRACT(VE) F—] OTHER(OT) <br /> M <br /> Lij 41 rt <br />