Laserfiche WebLink
V V <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES 1 <br /> V FOR LOCAL USE ONLY 1 � - <br /> J YES NO REPORT BEEN FILED? O YES NO I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT.I HAVE . <br /> REPORTED THIS INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 257807 OF <br /> y EPOR]( ATE CASE# �I�n `7 THE HEALTH AND SAFTY CODE <br /> L M V u Do o y / 9GNED-. DATE <br /> V NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATOR <br /> els <br /> V F REPRESE TING <br /> COMPANY OR AGENCY NAMOWNEWOPERATOR REGIONAL BOARD <br /> LOCALAGENCY OTHER r - ) <br /> n ¢ <br /> ADDRESS 6 <br /> STREET GTV <br /> NAME °TE ziv <br /> CO/N^TAC/TP/E+R�SONn L� �/� � PHONE <br /> El <br /> t� i [:] UNKNOWN V{�I GC'4(�� kcal i '-^i 'i <br /> YS y ADDRESS /, /STzzLI // <br /> NW. J <br /> ' giR '4 '�/ I' CITY <br /> J <br /> K V' SLATE Z <br /> FACILITYNAME(IF APPLICABLE) OPERATOR PHONE 1 <br /> s u S Sl y S !�. <br /> ADDRESS <br /> a f�� Seo c Kms- S <br /> Ll 3qS o <br /> \ r srREEr cm caurrry v <br /> y <br /> CROSS p STREET TYPE OF AREA O COMMERCIAL INDUSTRIAL 0 RURAL TYPE OF BUSINESS O RETAIL FUEL STATION <br /> �,L.,' �,�, O RESIDENTIAL O OTHER O FARM L OTHER <br /> LOCALAGENCY AGENCY NAME CON CTPERSON PHONE <br /> w <br /> P:- w1aii,411 <br /> v w� REGIONAL BOARD / PHONE <br /> Jy NAME QUANTITY LOST(GALLON <br /> OWN <br /> H - UNKNOWN <br /> I DATEDISCOVERED HOWDISCO RED INVENTORY CONTROL O SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> 2 aM YJkrTANK TEST O TANK REMOVAL O OTHER I <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) II <br /> w M M D D v r UNKNOWN 0 REMOVE CONTENTS REPLACE TANK CLOSE TANK <br /> 0 HAS DISCHARGE BEEN PPED7 REPAIR TANK O REPAIR PIPING CHANGE PROCEDURE ' <br /> p YES NO IF YESDATE M MI o o� r r LJ "THERM <br /> w SOURCE OF DISCHARGE TANKS ONLYiCAPACITY MATERIAL CALISE(S) <br /> 0 TANK LEAK UNKNOWN 7�_-GAL. Q FIBERGLASS O OVERFILL E::] <br /> RUPTURE/FAILURE I� <br /> ❑ PIPING LEAK AGE YRS STEEL O CORROSION O UNKNOWN/ <br /> O OTHER 0 UNKNOWN O OTHER O SPILL OTHER <br /> w w CHECK ON NLV t <br /> a <br /> ' UNDETERMINED O SOILONLV ( a GROUNDWATER O DRINKING WATER - (C HECK ONLY IF WA TER WELL SHAVE ACTUALLY BEEN AFFECTED) <br /> F CHECK oNF,6NLY <br /> 2 SITE INVESTIGATION IN PROGRESS(DEFINING EXTENTOF PROBLEM) 0 CLEANUP IN PROGRESS SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) <br /> UN NOACTIONTAKEN O POST CLEANUP MONITORING IN PROGRESS [�] NO FUNDS AVAILABLE TO PROCEED 0 EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> z O CAP SITE(CD) r I EXCAVATE 8 DISPOSE(ED) REMOVE FREE PRODUCT(FP) O ENHANCED BIODEGRADATION(IT) �k <br /> wc� O CONTAINMENT BARRIER(GET O,k EXCAVATES TREAT(ET) F7 PUMPS TREAT GROUNDWATER(GT) a REPLACE SUPPLY(RS) <br /> ¢ O TREATMENT AT HOOKUP(HU) O 4NO ACTION REOUIRED(NA) L] OTHER TOT) <br /> FO, a-Y) ap s- Fa,,n r 4;?-tis T- <br /> S tE' CFurr77u2s� te � ssc�ssuK� I <br />