UAR/PROP 65 PRE 2019 - Laserfiche WebLink

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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY REPORT BEEN FILED? I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT l HAVE ❑ YES NO YES ❑ REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF REPORT DATE( C CASE* THE H Ntl S Y E �M �M `-' D D �v v NED DAT NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATU m COMPANY OR AGENCY NAME REPRESE G ❑ OWNER/OPERATOR ❑ REGIONAL BOARD `1 Q LOCALAGENCY ❑ OTHER D o / 0. Q ADDRESS pct«� C,� dao/ STREET CRY STATE ZIP NAME CONTACT PERSON PHONE p� �yC Z t �� UNKNOWN `LJUI /� — �O R¢ 7,-�/ /y��f a ADD ESS ��a / / Q.f�fjQ"(f�/�� / / 4/ STREET CRY STATE ZIP FACILITY NAME(IF APPLICABLE) OPERATOR PHONE 0 Fa. s 1' C�cc S y 7t ISSj U ADDRESS 1 1 1 J o t J �D � �• STREET ~-(�' - CWNTYZIP CROSS STREET TYPE OF AREA COMMERCIAL a INDUSTRIAL ❑RURAL TYPE OF BUSINESS RETAIL FUEL STATION ( N �2 � ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER s LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE F-W w 6 H S YI oA4A x J 4a� 45/61- �3 S�fl w REGIONAL B PHONE IL G V`40 y (1) NAME QUANTITY LOST(GALLONS) U ❑ UNKNOWN (� 0 (2) vV/ u�i UNKNOWN 7�V\ Z DATE DISCOVERED Q HOW DISCOVERED ❑ IN ORY CONTROL ❑ SU URFACE MONITORING � NUISANCE CONDITIONS Lu m C..�M Lf.l OD JD y ❑ TANK TEST TANK REMOVAL OTHER DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK W M M D D Y Y > HAS DISC ARGE BEEN STOPPED? 7, xr� ❑ REPAIR TANK El REPAIRPIPING ❑ CHANGE PROCEDURE YES ❑ NO IF YES.DATE 1013 M a Di I V Y ❑ OTHER Lu SOURCED DISCHARGE TANKSONLY/CAPACITY MATERIAL CAUSE(S) 4 K LEAK ❑ UNKNOWN GAL. [:j FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE Ucr ❑ PIPING LEAK AGE 1, 5 YRS �STEEL ❑ CORROSION NKNOWN 2 ❑ OTHER ❑ UNKNOWN E::] OTHER ❑ SPILL ❑ OTHER Lu w CHECK ONE ONLY a 0 ❑ UNDETERMINED SOIL ONLY GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) F CHECK ON NLY z� s a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS E:] SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) crF U rn ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) z ❑ CAP SITE(CD) EXCAVATE&DISPOSE(ED) J RE OVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) E5 ow ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) le re v; cz cj a-,n�4-4"`aK)wee w l q S f� Ss�SSrx� �cc.o a MSC 05(4/87)