Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVI FOR LOCAL AGENCY USE ONLY <br /> ❑ <br /> YES <br /> REPORT BEEN FILED 7 YES NO I H EBY CERTIFY THAT I HAVE DISTRIBUTED INFORMATION ACCORDING TO THE NO ❑ <br /> D RIB ON S THE STRUCTIO SH ON THE BACK PAGE OF THIS FORM. <br /> REPORT DATE i CASE a <br /> ©M MI 4 �Y SIGNED (Q `JDATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE I ATUR <br /> REPRES G F__1OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGEN Y NAME <br /> Ir �. <br /> 0 LOCALAGENCY ❑ OTHER <br /> n0. <br /> cc AD ESS <br /> D• I / STREET CITY�/F/ /' STA / ��/ <br /> w NAME CONTACTPERSON PHONE <br /> 00 C ❑ UNKNOWN C/ ���/ <br /> a AAD/DRJESSS ///y/j/�� ��Jj '�J7 <br /> IL STREET '✓ � CITY �/`�1� STATE`-�" ' <br /> 2 �/ zIV O <br /> FACILITY NAME(IF APPLILE) OPERATOR PHONE <br /> UADDRESS <br /> 7 <br /> OJ /V STREET / Q�V/ d• CITY -� C/, V COU Z7S15 <br /> W <br /> ~ CROSS STREET <br /> LOCAL AGENCY AGEN Y NAME CONTACT PERSON PHONE <br /> Lu <br /> w U c2o9So <br /> Z 5 ) 4 <br /> w w REGIONAL BOARD PHONE <br /> (�) NAME QUANTITY LOST(GALLONS) <br /> Lu° O 0 / �v� <br /> a J UNKNOWN <br /> m o> (2) <br /> �z <br /> ❑ UNKNOWN \, <br /> I,_ DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL FVJ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lij <br /> z n 9 �J <br /> w F�M1 Y'M� / o� /o1 ` Yi �v E] TANK TEST [:j TANK REMOVAL ❑ OTHER A; <br /> w �V <br /> < DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> UNKNOWN ❑REMOVE CONTENTS ❑CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> ul M M D D Y Y <br /> HAS DISCHARGE BEEN STOPPED 7 0��/A/Q,,)� ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE E:]CHANGE PROCEDURE <br /> o [:] YES E] NO IF YES,DATE MI �f Ml /!Di DI Y Y ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> aF-1TANK LEAK KNOWN ❑ OVERFILL E::] RUPTURE FAILURE ❑ SPILL <br /> Ot U ❑ PIPING LEAK ❑ OTHER ❑ CORROSION Ek� UNKNOWN ❑ OTHER <br /> w w CHECK ONE ONLY <br /> Na <br /> O ❑ UNDETERMINED ❑ SOIL ONLY GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w cn <br /> ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> 0 <br /> EE ❑ LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J (SEE BALK FOR DETAILS) <br /> FD O ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Lu <br /> w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) OTHER(OT) <br /> c/) / l <br /> zLu <br /> I <br /> ccol,L"(_�� <br /> 0 U U <br /> HSC 05(MO) <br />