Laserfiche WebLink
UNDERGROUND STORAGE TANK (UST) SITE - UNAUTHORIZED RELEASE/CONTAMINATION REPORT <br /> EMERGEN Y HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> E3 Yea <br /> o REPORT BEEN FILED? ❑Yes �NO I HEREBY CERTIFY THAT I AMA DESIGNATED GOVERNMENT EMPLOYEE AND THAT 1 HAVE <br /> REPORT DATE CASE# THEO EALO THIS -A-INFORM <br /> Ci <br /> TION T(/ AL OFFICIALS PURSUANT TO SECTION 25180.]OF <br /> 22,�/ <br /> a- <br /> NAME OF INDIVIDUAL FILING REPORT <br /> G{ PHONE 3Yy nI UHE <br /> 1V-X-r0LJ (2o9)9�T- <br /> m E RESENTIN COMPANY OR AGENCY NAME <br /> 0 <br /> 'OCAL AGENCY ❑REGIONAL BOARD iJD <br /> S ❑OWNER/OPERATOR ❑OTHER lJ �/ C./ T� <br /> rc ADDRESS <br /> (� Rr\� r7 <br /> STREET( J, CITY STATE ZIP5�� <br /> w NAME <br /> a: 8 D Q l2 <br /> sui Cip� I I'LPERSON <br /> n PHONE <br /> ❑Unknwn OAm^ <br /> ADDRESSw a4 W�/� L <br /> STREET ) 7p <br /> CITY STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE0 POT <br /> a,42 qL(-G i ) <br /> ADDRESS <br /> a / 0 <br /> ( R _ wa � / <br /> CITY cLC� COUNTY ZIP`/JZ/� <br /> An CROSS STREET <br /> w <br /> LOCAL AGENQV AGENCY NAME PHONE <br /> i <br /> P= 7&r w.:7 CD. 07 ✓� /17� arc f�I rY -3y20 <br /> Mw I REGIONAL BOARD PHONE <br /> o/o) 9(,.. .3�7 <br /> (1) NAME QUANTITY LOST(GALLONS) <br /> w <br /> oUnknown <br /> a� <br /> � ❑ Unknown <br /> i DATE ISCO ERED HOW DISCOVERED ❑Tank Test ank Removal <br /> Nuisance Conditions <br /> w <br /> w 12 //,IfL]Inventory Control ❑Subsurtace Monitoring ❑Other <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> aEJ <br /> i Remove Contents ElClose Tank <br /> w Unknown ❑Repair Tank ❑ Change <br /> Procedure <br /> o HAS DISCHARGE BEEN STOPPED? ❑ Replace Tank .Other RX-4yt�/VQr��Qh <br /> o ❑Yes ❑ No IF YES,DATE LJ4)�a L&D n ❑ Repair Piping <br /> Qw SOURCE OF DISCHARGECAUSES) <br /> Um <br /> D¢ ❑Tank ❑Piping ❑Dispenser ❑Delivery rgble ❑Spill ❑Overtill Ph sical/Mechanical Damage ❑Corrosion <br /> 00 ❑Submersible Turbine Pump(STP) Omer( / Installation Problem Unknown ❑Other <br /> cow CHECKONEONLY <br /> v )lndetenDned ❑Soil Only ❑Groundwater ❑Drinking Water—(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w. O Open-Site Assessment [I Open-Vedfcetion Monitoring <br /> w a 0 Open-Assessment&Interim Remedial Action ❑Open-Inactive <br /> w ❑Open-Remediation ❑Closed—No Further Action Required <br /> CHECK APPROPRIATE ACTION(S) <br /> Q Human health exposure control? ❑Yes ❑No ❑Unknown <br /> Groundwater migration control? ❑Yes ❑No ❑Unknown <br /> a ❑No Action Required(NAR) ❑Excavate&Treat(ET) ❑Treatment at Hookup(TH) ❑Other <br /> w ❑Excavate 8 Dispose(ED) Free Product Removal(FPR) Replace Supply(RS) <br /> rc <br /> ti <br /> z <br /> z <br /> E <br /> s <br /> 0 <br /> U <br /> SWRCR Leak Report Form http://www.swrcb.ca.gov/water_issues/programs/ust/forms/ Rev.02/01/2012 <br />