Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICESEOR LOCALAGENCY U ONLY <br /> Q YES Q NO REPORT BEEN FILED 4 ❑YES E:] NO 1:HEREBY:CERTIFYT t ESIGNATED GOVERNMENT EMPLOYEE ANDTHAT E NAVE: <br /> :.REPORTED.: IN. T LOCAL OFFICIALS?.URSUANT T(:SECTION 25180 OF. <br /> REPORTOATE CASE* <br /> THE HEAL <br /> t ' G <br /> ES <br /> OM SM '1 0� �r 0 v :SIGNED ...;:....DATE...`.:. ;<. <br /> NAME OF INDIVIDUAL FLING REPORT PHONE <br /> SIGNATURE <br /> w REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANYORAGENCYNAME <br /> °C LOCAIAGENCY OTHER r <br /> a ❑ �r �oe� ..�h Loc+( e.tiL, s4,.c-r <br /> Q ADDRESS U C s^ <br /> C,1 Aµ <br /> STREET J{�+,C'�' <br /> CITI STATE ZIp <br /> L NAMME CONTACT PERSON (t PHONE <br /> ZQ J go <br /> 2VC V G\e1�n� ❑ UNKNOWN SJ �CV VC.`eK-�h4 ( t) L1 <br /> a ADDRESS <br /> 3 STREET CITr STATE ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> OUt ADDRESS \^�,., C�^ 1 ^� `l <br /> W Z3 lS �� �/`✓STRE� J cmF�� �" 1, t�1 h G S—Z0ap <br /> T <br /> y CROSS STREET TYPE OF AREA ❑COMMERCIAL Q INDUSTRIAL a RURAL TYPE OF BUSINESS RETAIL FUEL STATION <br /> St- RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER <br /> LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> Ww <br /> n �oq ��, '► -�•vvi� ��..\lt (Zoq) 46t-3c./L8 <br /> w REGIO AL BOARD <br /> � ` PHONE <br /> �l (cllb)3W/^S(GO o0 <br /> y (11 NAME QUANTITY LOST(GALLONS) <br /> wp <br /> Jo�ty�-. �v. (�d��..5 UNKNOWN <br /> _ (Z) 2 - <br /> 1 Gv�L UNKNOWN <br /> z GATE DISCOVERED HOW DISCOVERED F7INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w �J <br /> M M ZDdo o v y ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY)���,,,fff <br /> w M M o o v y UNKNOWN ❑ REMOVE CONTENTS ❑ REPLACE TANK CLOSE TANK <br /> HAS DISCHARGE BEEN STOPPED Z REPAIR TANK ❑ REPAIR PIPING CHANGE PROCEDURE <br /> al wYES ❑ NO IF YES.DATE SMI 4 M Zo 0 0 rl �r ❑ OTHER <br /> /w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) <br /> ❑ TANK LEAK UNKNOWN GAL Q FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE <br /> 2 ❑ PIPING LEAK AGE YRS rjVr STEEL ❑ CORROSION UNKNOWN <br /> ❑ OTHER ❑ UNKNOWN 777❑��� OTHER a SPILL a OTHER <br /> w w CHECK ONE ONLY <br /> Ua <br /> ?-- ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Zy <br /> ❑ SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> cc <br /> U ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS a NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ CAP SITE(CD) ❑ EXCAVATE 6 DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> Lu <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE 6 TREAT(ET) ❑ PUMP 5 TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) <br /> ❑ TREATMENT AT HOOKUP(FID) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br /> CC <br /> WQ�MIH C.��Oh v�.a�'C� CSV✓�r1G �QK� -'�:TVG� �' M lT�m <br /> Lu <br /> o� w;+k 50'l1( re5U ^{Tr• J7 <br /> J <br /> HSC05(4w) <br />