CO0015375 - Laserfiche WebLink

Home Browse Search

p( - U-0 ;L— UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY REPORT BEEN FILED? YES Q NO ® YES Q NO i HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. REPORT DATE CASE of VM /M Zf O /Y /— Dd / SIGNED DATE NAME OF INDIVIDUAL FILING REPORT PHONE SIGNA R m 7)/�N /S) e---r4 All"Y r"611" (a.a 9) 5,16a S 7b 71 REPRESENTING OWNER/OPERATOR ❑ REGIONAL BOARD I COMPANY OR AGENCY NAME R ❑ LOCAL AGENCY OTHERIII ADDRESS STREET IVA / CITY STATE ZIP 9 Y w NAME CONTACTPERSON PHONE J Lum z / a 0 UNKNOWN 0-d ADDRESS G� / ////1/� STREET CITY STATE ZIP FACILITY NAME(IF APPLICABLE) OPERATOR PHONE Lv�sT / ' c�' G,Z� X0 9) y U ADDRESS 6,/V L Lr/ocON Jr, V-"- O w STREET CITY COUNTY ZIP N CROSS STREET O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE z w y, 10 r- r- w w REGIONAL BOARD PHONE J C7 CL` c v � I j yG / ( ) w (t) NAME QUANTITY LOST(GALLONS) uv� E�a�� C9c�/��- Giro ens - S OW J �� ❑ UNKNOWN m z IZI O c- ❑ UNKNOWN �--- z DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS � w o MI MI VDI DI b YI ` v E] TANK TEST ❑ TANK REMOVAL OTHER y < DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) a ? O UNKNOWN ❑REMOVE CONTENTSE]CLOSE TANK d REMOVE ❑REPAIR PIPING (� 6M M D D Y Y p HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE U) YES ❑ NO IF YES,DATE 0.1 MI O D D oyl Y ❑REPLACE TANK OTHER 0,1_CCOA Z:,/6 SOURCE OF DISCHARGE CAUSE(S) w L) ❑ TANK LEAK ❑ UNKNOWN OVERFILL ❑ RUPTURE/FAILURE SPILL N O ❑ PIPING LEAK OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER Lu w CHECK ONE ONLY U UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION a y ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS L) ❑ REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) EXCAVATE d DISPOSE(ED) ) ❑ ENHANCED BIO DEGRADATION(IT) J (SEE BACK TOR DETAISI 23 0aZ ❑ CAP SITE(CD) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP d TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) w w� rc� Lu a ❑ CONTAINMENT BARRIER(CB) I k I NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) ❑ VACUUM EXTRACT(VE) Y❑� OTHER(OT) (_r,4/L L 4J� L /t-� TC�� o /�� /3 LT" /)-4/0 C,—h-eX1r 0kF/ l re per/Glo - Co/v T/i f-7) n if T(f ZeIk I a c�c� HSC 0.5(890)