Laserfiche WebLink
s <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERV F.OR LOCALAGENCY.USE ONLY: <br /> REPORT BEEN FILED? t:#iEREBY CERTIFY TMST I ANE IL;OESIGNAfEd GOVERNMEFif EMPI OYES AND TEAT 1 HAVE: <br /> YES NO =YES NO REPORTED IR )NFOAMATION TO IC(ALS PURSUANT TQ SECT(Qtwt 25180:7 OF: <br /> MTHE HEALTHTWO <br /> DATE ASE REPORT <br /> UMI V SAFfY, `te�,tn <br /> :SIGNED GATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONEf SIGNATURE <br /> n COMPANY OR AGENCY NAME <br /> w REPR ENTING ❑ pWNER/OPERATOR ❑ REGIONAL BOARD � �� � I It I���� � C� <br /> ¢ LOCAL AGENCY ❑ OTHER �-N CI A-Q,�,(�;f <br /> O <br /> a <br /> ¢ ADDRESS Fry,'( <br /> S�Y'�1•�� ✓!`J STATE L� ztp <br /> NAME CONTNTPERSON PHONE <br /> rn i-- �vk �C l V o ❑ UNKNOWN �� O� -�C.`�� �G ���r 74 Y/ <br /> a ADDRESS <br /> ¢ L O 'j�(A`{STREET`!//V�'W• f'P/� Vv Cm, <br /> FACILITY NAME PAPPLICABLE) OPERATOR PHONE <br /> � fit r'�G ►� �� `t��r� <br /> ADDRESS <br /> UtO STREET W CITY COUNTY ZIP <br /> yCROSS STREET TYPE OF AREA ❑COIJiMERCLAIL ❑INDUSTRIAL ❑RURAL TYPE OF BUSINESS ❑ RETAIL FUEL STATION <br /> ❑RESIDENTIAL ❑OTHER I ❑ FARM ❑ OTHER <br /> LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> Co, tlt-6(<< i } V <br /> 1 REGIONAL BOARD PHONE <br /> (�) / NAME QUANTITY LOST(GALLONS) <br /> z Q/e i r,-r /1 C UNKNOWN <br /> 0 (2) <br /> u�i ❑ UNKNOWN <br /> z DATE DISCOVERED c HOW DISCOVERED INV5Kf0RY CONTROL ❑ SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> w M 3M vD D Y j v ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Ul M D D V Y <br /> ❑ UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK <br /> M <br /> > HAS <br /> [7 <br /> RGE BEEN STOPPED? �J ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> p YES � NO IFYES,DATE �i t 0 ❑ OTHER <br /> M M Q D Y V <br /> N SOURCE OF DISCHARGE TANKS}ONLY/CAPACITY MATERIAL CAUSE(S) <br /> ED TANK LEAK UNKNOWN / j b 0 Q GAL. ❑ FIBERGLASS ❑ OVERFILL �FRREA:AILURE <br /> ElPIPING LEAK AGE YRS STEEL CORROSION N <br /> ❑ OTHER UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER <br /> WTI CHECK E ONLY <br /> UNDETERMINED SOIL ONLY a GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONS ONLY <br /> n <br /> ¢ F-1SITEINVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> c7i h I ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> 0 4 ❑ CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) REMOVE FREE PRODUCT(FP) ENHANCED BK)DEGRADATION(IT) <br /> 2 F-1CONTAINMENT BARRIER(CB) ❑ EXCAVATE 6 TREAT(ET) ❑ PUMP 8 TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENTAT HOOKUP(-I(4 ❑ NO ACTION REQUIRED(NA) OTHER(OT) <br /> f rd 4 P,c( 6C t t j:t� ,,cG , <br /> Z f�1,,,e�he� SSafe Cis scssah�,.� be f��u ;2 e.�L �o dre <br /> 2 1 G fu r� i�,d 9A4,0wf'd 9::' Cl h 7tt Oft<A,gt h an <br /> jy Ht,,,_ 6t )r r�w� �.. <br />