Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
-U1 (30 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES `FOO LOCAL AGENCY USE ONLY . <br /> REPORT BEEN FILED? <br /> VES NO YES I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ ❑ NO <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE RACK PAGE OF THIS FORM <br /> REPORT TE CASES l <br /> 7y SIGNE6 DATE J <br /> NAMED INDIVIDUAL FILING REPORT PHONE SIGNA R <br /> I�,T'i c<-- 4 i s cad �g- <br /> w REPRESENTING ❑ OWNER/OPERATOR ❑ REGK)NALBOARD COMPANY OR AGENCY NAME v OF <br /> S LOCALAGENCY ❑I ' 1OTHER <br /> � <br /> ¢ <br /> ADORED �. WISP/-f/t/ �f©�� YC✓ C J/�yI <br /> J'3 3fRFET CRY STATE ZIP <br /> J y as <br /> NAME <br /> 0MyE[/�Lh/ � '��"y-�'�`^��/✓/['�7' CONTACT PERSON <br /> PHONE <br /> ./ � (0 ) J 71- /T❑ UNKNOWN D/7 I/C- �y <br /> i Q) VoL oWA ^ <br /> ADDRESSDr NK�� ✓ , (f <br /> (/ <br /> w <br /> STREET CRY STATE IP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> AllADDRESS �$VI li W Ata�I�/�{ • V/lC� <br /> O <br /> y CROSS STREET <br /> go bim <br /> O LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> 3 m t <br /> w� <br /> tri S <br /> w w REGIONAL BOARD jj PHONE <br /> E <br /> w (i) NAME QUANTITY LOST(GALLONS) <br /> Uw <br /> <J UNKNOWN <br /> N O (2) <br /> m� <br /> 7� <br /> y ❑ UNKNOWN <br /> i DATE DISCOVERED yn HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> are <br /> DATE DOTHER <br /> ml ISCHARGE BEGAN ly�y ❑ TANK TEST ❑ TANK ME�OD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) II <br /> M D D Y y UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK 8 REMOVE E::]REPAIR PIPING <br /> II]0 HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK R FILL IN PLACE ❑CHANGE PROCEDURE <br /> O <br /> o ❑ YES NO IFYES,DATE ml MI ol d Y1 y F-1 REPLACE TANK ❑OTHER <br /> iD SOURCE OF DISCHARGE CAUSE(S) <br /> ¢j ❑ TANK LEAK ?C UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> w0 ❑ PIPING LEAK ❑ OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> H i CHECK ONE ONLY <br /> O UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> HECK EONLY <br /> w� F-1NOACTION TAKEN F-1PRELIMINARYSITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> ,¢may ❑ LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE B DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> J ISH eWF Wnoflubl <br /> 0o ❑ CAP SITE(CO) ❑ EXCAVATE&TREAT(ET) ❑ PUMPB TREATGROUNDWATER(GT) REPLACE SUPPLY IRS) <br /> wr <br /> wa ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTON REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> uw �� <br /> 711 <br /> HSG to IS'aol <br />