Laserfiche WebLink
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 ❑ YES NO <br /> REPORT BEEN FILED z I HEREBY CERTIFY`HAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ ❑ <br /> DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PAGE OF THIS FORM. <br /> REPORT DATE CASE s <br /> I MI d MI ./of 6 d F.��3 v SIGNED DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> m <br /> REPRES NG ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> cc LOCALAGENCY ❑ OTHER q �1 01 <br /> cc <br /> ADDRESS � S��G�E Ap (fA (s G-O � 0 - <br /> Y� Sa� 7vli. �u�n � � <br /> STREET <br /> CITY STATE ZIP <br /> NAME CONTACTPERSON PHONE <br /> w _ <br /> z ��i C��(V :(/L?Z- ❑ UNKNOWN <br /> a a ADDRESS <br /> STREET CITY STATE ZIP <br /> EAD <br /> ITY NAME(IF APPLICABLE) <br /> E)n) OPERATOR PHONE <br /> Cp [/ <br /> e�f- [("v <br /> URESS <br /> 3(_2c) <br /> STREET CITY COUNTY S �I ZIP <br /> w <br /> ~ CROSS STREET <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE ` <br /> z <br /> w <br /> w PHONE <br /> REGIONAL BOARD I <br /> m (�) NAME QUANTITY LOST(GALLONS) <br /> 00 ❑ UNKNOWN <br /> Z <br /> Q J <br /> m O (z) <br /> /P u ❑ UNKNOWN (�(� <br /> Z DATE DISCOVERED HOW DISCOVERED ❑ I NTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> ul ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> W MI -�'l DI t Y ? <br /> W <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DI�=K <br /> K ALL THAT APPLY) <br /> a UNKNOWN ❑REMOVE CONTENTS &REMOVE ❑REPAIR PIPING <br /> w M M D DI Y Y <br /> HAS DISC GE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK S FILL IN PLACE ❑CHANGE PROCEDURE pG <br /> rVi) YES,DATE oI r� v REPLACE TANK OTHER <br /> o YES ❑ NO IF MI M o ❑ ❑ <br /> Lu <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE a SPILL <br /> U)v ❑ PIPING K ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> Lu w CHECKgtf ONLY <br /> U)a <br /> UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> cn <br /> U ❑ REMEDIATION PLAN a CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) a CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE 3 DISPOSE;ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> (SEE e K FCR CEf j <br /> o O ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP 8 TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Lu a❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> �—f/u� ss Gf cs/c'rs i�rr. �.':l/ P c«s CL�y -'�w eyle <br /> w <br /> --es <br /> �t%/iiL� h r luG fc, <br /> HSC 05(MOO <br />