Laserfiche WebLink
090 VYL <br /> .. �-o <br /> �' UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)!CONTAMINATION SITE REPORT <br /> EMER HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY > <br /> R y` REPORT BEEN FLEA? i HEREBY CERTIFY THAT 1 AM A DESIC�1'tllTED GOVERNMENT EMPI.OYEE ANO TKAT I HAVE <br /> S NO Cl Y>~s REPORTED T)(IS INFORMATION TO LOCAs OFFIGMS PURSUANT TO SECTION 251KI OF <br /> PORT OATS CASE THE H AND F- <br /> Y 3 <br /> I II I f / <br /> I DATE/ <br /> NAM OF INDIVIDUAL.FLING REPORT PHONE SIGNAT RE <br /> (205)U /7 Ale <br /> REPRESENTING OYYNERIOPERATOR Q REGIONAL BOARD COMPMIYORAGENLYNAME <br /> go a L AGENCV ❑ OTHER / ✓/CCS �y <br /> a ADDRESS �L 95 o j - <br /> STIt♦EEfter SPATE 2W <br /> NAMEuNswawN CONTACTPERSON PHONE <br /> Z— <br /> R a ADDRESS � Lo <br /> cc <br /> aqid RM,,(� CITY STATE rip <br /> FACLITY E IF APPLICABLE) OPERATOR PHONE <br /> � ADDRESS <br /> COUNTY 21P <br /> H CF1055 STREET NPE �� RCIAL Q INDUSTRIAL Q RURAL TYPE OF BUSINESSJ�LAETAIL FUEL STATION <br /> Q OTHER Q FARM Q OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PH-O7N�E� <br /> G L <br /> a` REGIONAL BOARD PHONE/ <br /> 111 NAME QUANTITY LOST(GALLONS) <br /> U� UNKNOWN <br /> (2) <br /> H Q UNKNOWN <br /> r DATEOISCOVEREO IIDWDtSCOVEREO 0 INVENTORY CONTROL Q SUBSURFACE MONITORING Q NUISANCECONDITIONS <br /> t2w u o o r r TAW TEST TANK REMOVAL Q OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> (a(ppyVN �REAIOVECONTENTS 0 REPLACE TANK CLOSE TANK <br /> Lu <br /> n FiAS OISGHARG6 BEEN STOPPEO T a REPAIR TANK Q REPAIR PIPING CHANGE PROCEDURE <br /> a YESNO FYES DATE o r OTHER 2 mn vrca� <br /> SOURCE OF DISCHARGE TANKS ONLY)CAPACITY MATERIAL CAUSE(S) <br /> Q TANK LEAK -1111OWN GAL. C-FIBERGLASS OVERFILL Q RUPTUREIFALURE <br /> 0 PIPINGL.EAK AGEYRS STEEL ❑ CORROSION Q�,UNKNOWW <br /> OTHER Q UNKNOWN Q OTHER Q SPILL Q OTHER <br /> w CHECK ONE ONLY <br /> 0 UNDETERMINED SOILONLY 0 GROUNIDWATER Q DRINKWGWATER (CHECK ONLY IF WATER VVELLS HAVE ACTUALLY BEEN AFFECTED) <br /> r CHECK ONE ONLY <br /> z�^ <br /> a i O SITE INVESTIGATION W PROGRESS(OEFWNG EXTENT OF PROBLEM) a CLEANUP 1N PROGRESS SIGNED OFF(t�EAUVl1P COMPLETER OR UNNECESSARY) O <br /> °C r <br /> u h Q NO ACTION(TAKEN 0 POST CLEANUP MONITORING W PROGRESS No FUNDS AVALABLE TO PROCEED EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> z a CAP SITE(CO) Q ExCAVATE a DISSPOSE(ED) 0 REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) <br /> W <br /> Q CONTAINMENT HARRIER(CB) 0 EXCAVATE A TREAT(ET) Q PUMP i TREAT GROUNDWATER(OT) Q REPLACE SUPPLY(RS) <br /> 0 TREATMENT AT HOOKUP(FM Q NO ACTION REQUIRED(NA) Q OTHER(OT) <br /> I�P-7-He2 J/Te �}SS��S.�fl 1.t1 c� g� ,2G�£ cl ,x7� <br /> 'o o/J •9s �c�L1 ,> <br /> iIn" <br />