Laserfiche WebLink
� - <br /> ri <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) 1 CONTAMINATION SITE REPORT <br /> EMERGENCYHAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> F-1YES NO REPORT BEEN FILED ? ❑ YES ❑ NO I HEREBY CERTIFY THAT I AM A D01ONATED GOVERNMENT EMPLOYEE AND THAT I HAVE <br /> ,REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO . SECTION:I25100.7. OF: <br /> REPORT DATE CASES THE HEALTH AND SAFTY COD <br /> pit-ar <br /> /M � M � o FYI y xslaeEO . .,::oarE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> 07 <br /> REPRES ING ❑ OWNERIOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME CC -- - <br /> p LOCAL AGENCY ❑ OTHER LC /// C Q ov/C <br /> ADDRESS /�/L'( //�� . / c L ?-5-dol <br /> j <br /> U / ' BTPEE�f V e. <br /> WY ` - !1 9fpTE - / ZS�J(J/ <br /> f Lq NAME CONTACT PERSON PHONE <br /> 77 <br /> i � XXO /! E] UNKNOWN /fo Ei' �/ S Ap/'7 <br /> Sa ADDRESS1)JJ'' q gs�(J6 <br /> 2 l.�/ 9TRE �V CT/ OL /Ch <br /> 3lATE lJ 21P <br /> FACILITY NAME (IF APPLICABLE) OPERATOR PHONEEx <br /> a ADDRESS (� rh- g (^ L_/ s /-o I�V ' I 537-7 1 <br /> — 077 <br /> l �` STFlEECr�? Gc �y�/r W _ cry 6 YV CIC 4 7 T <br /> couKnh 07 rN <br /> m CROSS STREET TYPE OF AREA COMMERCIAL ❑ INDUSTRIAL ❑ RURAL TYPE OF BUSINESS gETAIL FUEL STATION <br /> Grp h ❑ <br /> RESIDENTIAL OTHER ❑ FARM ❑ OTHER <br /> H LOCALAGENCY AGENCYNAME CONTACTPERSON <br /> PHONE <br /> is <br /> LU REGIONAL BOARD vPHONE <br /> y (1) NAME QUANTITY LOST (GALLONS) <br /> H o UNKNOWN <br /> 0 (� <br /> I an /&>ez cle -C s O /�/�P <br /> UNKNOWN <br /> I DATEDISCOVEREO HOWDISCOVERED ❑ INVENTORY CONTROL SU SURFACE MONITORING <br /> yp�v' p' ❑ ❑ NUISANCE CONDITIONS <br /> L o Vy / v ❑ TANKTEST ❑ TANK REMOVAL �ER Ste{ r <br /> S DATE DISCHARGE BEGAN MET140D USED TO STOP DISCHARGE (CHECK ALL THAT APPLY ff <br /> E- ¢ UNKNOWN ❑ REMOVECONTENTS ❑ REPLACETANK CLOSE TANK <br /> w ' M M D 0 Y V <br /> Q HAS DISCHARGE BEEN STOPPED ? ❑ REPAIRTANK REPAIRPIPING CHANGE PROCEDURE <br /> F3 ❑ YES ❑ NO IFYES, DATE ❑ OTHER <br /> M M DI O V Y <br /> w. SOURCE OF DISCHARGE TANKS ONLYYprAPACITY MATERIAL CAUSES) <br /> ❑ TANK LEAK UNKNOWN O � r'DD GAL. ❑ F EPGLASS ❑ OVERFILL ❑ R URE/FAILURE <br /> ❑ PIPING LEAK AGE VRS STEEL CORROSION UNKNOWN <br /> 1 ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> w CHECKONEONLY <br /> Fl UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONSONLV cp <br /> l � y <br /> ¢ a ❑ �SFTE INVESTIGATION IN PROGRESS (DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF (CLEANUP COMPLETED OR UNNECESSARY) .+ r <br /> f UN NO ACTIONTAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S) (SEE BACK FOR DETAILS) <br /> o zp F-1CAP SITE (CD) E::] EXCAVATE A DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION (IT) f <br /> 2 ❑ CONTAINMENT BARRIER IDS) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY IRS) 1 <br /> ❑ TREATMENT AT HOOKUP (HU) ❑ NOACTIONREOUIRED (NA) ❑ OTHER (OT) <br /> 8 45k -- <br /> 1 <br /> fKscoslem) <br />