Laserfiche WebLink
!1 <br /> r <br /> f <br /> 'i 1 `1 1 <br /> 4/L.�V <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)I CONTAMINATION SITE REPORT <br /> F <br /> RGENCY HAS STATE OFFICE OF EMERGENCY SERVICES } <br /> REPORT BEEN FILED t FOR LOCAL-AGENCY 3JSE pNLY <br /> YES NO YES ED NO i HEREBY CEiiTIFYT)tAT'I'HAVE f])SfRIBUTEp.T}{)S(NFbRMATfON ACCORDINGTO <br /> THE I <br /> REPORT DATE OISTRIBUTIOW'SHOWN ON THE WSfRUCTIDN SHEET ON THE BACK PAGE OFTHI5 FORM <br /> SIGRED DATE <br /> NAME OF WOIVIDUAL <br /> FILING REPORT REPORT <br /> PHONE <br /> E 9 SIGNATURE <br /> G REPRESENTING OWNE RATOR Ej REGIONAL BOARD <br /> �.G <br /> COMPANY OA AGENCY NAME <br /> LOCAL AGENCY ❑ OTHER / f D <br /> Q ADDRESS �7 <br /> SAS' <br /> Lt)¢• q <br /> w Er <br /> wNAME <br /> cm $TATE ZIP <br /> m CONfT�AC/TPEJRSON i PHONE <br /> 7 <br /> OZ a UNKNOWN <br /> CL <br /> toi[}�� <br /> a ADD SIS lief L�� iIr n�� � ) <br /> Lu I <br /> STREET CITY i( '7 <br /> FACILITY NAME STATE <br /> }(IF APPLICABLE) OPERATOR j <br /> Z U • W GV PHONE f} <br /> o <br /> c ADD �lX . � <br /> o 4 -' S-t�GLC la s <br /> t�-�� ?5j o <br /> m CROSS STREET crry COQZIP <br /> y iDcCAI A{G'ENC�Yi C AGENCY NAME CONTACT PERSON o PHONE lj��. (/ 1' <br /> Z V e.,-.7+ 6J ice., e a4� I V J <br /> w Z YY "'���...fYYG��CCC <br /> aG REGIONAL BOARD PHONE <br /> U (�) i NAME I i QUANTITY LOST(GALLONS) I <br /> Z <br /> m aIj - UNKNOWN F <br /> UNKNOWN l <br /> O�/A)�TS DISCOVERED yam/] HOW DISCOVERED ❑ INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS 1 <br /> y V All t` 4I •pi `0 Y ❑ <br /> L TANK LEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) i( <br /> s � � UNKNOWN E]REMOVE CONTENTS;❑CLOSE TANK S REMOVE ❑REPAIR PIPING <br /> w <br /> 0 <br /> HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK E FILL W PLACE ❑CHANGE PROCEDURE <br /> h o YES ❑ NO IF YES DATE Q*I a",4 oI �v t v ❑REPLACE TANK ❑OTHER r <br /> k SOURCE OF DISCHARGE CAUSE(S) I <br /> bIL I <br /> o TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ IRUPTUAEIFAILURE [:j SPILL 4 <br /> ti ❑ PIPING LEAK ❑ OTHER CORROSION ❑ UNKNOWN ❑ OTHER <br /> N Lu CHECK ONE ONLY <br /> UNDETERMINEDSOIL ONLY GROUNDWATER 1 ; <br /> ❑ ❑ ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) � <br /> CHECK ONE ONLY ` <br /> z iJQ NO ACTION TAKEN Q PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑.'� POLLUTIONCHARACTERIZATION t <br /> w r`1 <br /> Q <br /> m ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ' PAST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMP(_ETEOOR UNNECESSARY) CLEANUP UNDERWAY <br /> s <br /> CHECK APPROPRIATE ACTION(S) <br /> k (smSA"FM DMALA EXCAVATE E DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(in <br /> I o o CAP SITE(CD) EXCAVATE b TREAT 'i ;h <br /> w�. <br /> ❑ ❑ (£T) ❑ PUMP 8 TREAT GROUNDWATER{GT)❑ REPLACE SUPPLY(AS) <br /> Lli <br /> U a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT A7 KUP(HU) ❑ VENT SOIL(VS) <br /> s ❑ g <br /> VACUUM EXTRACT(VE) �OTHER(OT) <br />� w c��L�� 5.1•� vt�e � fa <br /> 6 i <br /> U <br /> i <br /> ,< <br /> �} HSC 05189% <br /> p <br /> i5 it <br />