Laserfiche WebLink
10 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> YES NO REPORT BEEN FILED? YES NO aEPORTED R THATjMXDINFORMATION TD S]G T D r QV R Pi RSUANT TO EMKoyee <br /> Ab-- :[HAVE <br /> OF <br /> REPORTOATE CASES THEN DSAMOOM <br /> ©M 3M ? 0 t+ y 6 Y <br /> NAME OF INDIVIDUAL FILING REPORT PH SIGNATURE <br /> m v i d CCh Jt�5 ) <br /> o REPRESENTING OWNERIOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME <br /> p V LOCAL AGENCY OTHER Sq+� �aa a.ik LDS +( uG41�L,Lu <br /> i ✓. <br /> ADDRESS !S [ (� <br /> loO1 _ L{ 2L�+'+ �_D. f�o>C2oa �`��+a4c`� -. C.l� �a <br /> STREET CITY STATE ZIP <br /> NAME CONTACTPERSON <br /> h• �- PHONE <br /> Z� �r a�/� ,- , [] UNKNOWN �o z�Q <.W- {2�() SIS^C73s� <br /> S a ADDRESS <br /> W <br /> WlZA"44� IR Los ��e�s C f� <br /> STREET cnv STATE <br /> ZIP <br /> FACILITY NAME <br /> ``(IF APPLICABLE) OPERATOR PHONE <br /> o �o✓�si�74?r �r oraTor �a (Ct �� (Z-1) S�3S -033'3 <br /> ADDRESS <br /> �V <br /> STREET �7 Cc <br /> P <br /> RETAIL <br /> CROSS STREET TYPE OF AREA COMMERCIAL Z INDUSTRIAL RURAL TYPE OF BUSINESS <br /> {' FUEL STATION <br /> -1/,I, 1, 1 L_]RESIDENTIAL E]OTHER FARM LXOTHER <br /> LOCAL AGENCYAGENCY NAME CONTACT PERSON <br /> _ 1 /' /PHONE <br /> A <br /> �ptyi (� ks <br /> UPREGIONAL BOARD (�� I R (Rob)1 <br /> Ce-r��✓'wL �C��L VorcL�r 4.�0 S 1RTb1 <br /> y (�1 NAME QUANTITY LOST(GALLONS) <br /> UNKNOWN <br /> M O r o UNKNOWN <br /> Z DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> Lu <br /> d M L(M t Il D Dil S-Y -7-Y D TANK TEST TANK REMOVAL OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> w M M a n yl yl UNKNOWN REMOVECONTENTS REPLACETANK CLOSE TANK <br /> p HAS DISCHARGE BEEN STOPPED? El REPAIR TANK REPAIR PIPING CHANGE PROCEDURE <br /> p 14 YES [--] NO IFYES,DATE q. (a ©p &y -f-Yl [::] OTHER ' <br /> LijN SOURCE OF DISCHARGE TANKS ONLY APACITY MATERIAL CAUSE(S) <br /> O TANK LEAK � UNKNOWN 2 c O {� b?' GAL, FIBERGLASS OVERFILL E:] RUPTURE/FAILURE <br /> PIPING LEAK AGE 2 S YRS STEEL CORROSION [y UNKNOWN <br /> OTHER UNKNOWN OTHER 0 SPILL L:] OTHER <br /> Lu w CHECK ONE ONLY <br /> a <br /> U 0 UNDETERMINED SOIL ONLY GROUNDWATER DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS 0 SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> U) NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS NO FUNDS AVAILABLE TO PROCEED L] EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 0 0 F7 CAP SITE(CD) F7 EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> Lu <br /> 0 CONTAINMENT BARRIER(C$) EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> TREATMENT AT HOOKUP(HU)1 NO ACTION REQUIRED(NA) f 11 {Q OTHER(OT)11 r <br /> V p�-v.�wt��r CP•.Ta w.i v�aa:'t�o•� �{,� C-S 47-I TQ•.,F-S GQ T C3"k vle_`Io v 0, <br /> z <br /> Lu <br /> HSC 0544&7) <br />