UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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UNDERGROUND STORAGE TANK UNAUTHORIZED R .pK /CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES f REPORT BEEN FILED Z BY CERTIFY THAT 1 A A I D GOVERNMENT EMPLOYEE AND THAT I HAVE E:] YES NO [::]YES NO REPORTM INFORMATION FICIALS'PURSUANT TO SECTION 25180.7 OF REPORT DATE CASE A THE HEA SAF] I- M M D Y v DATE NAME OF INDIVIDUAL FILING REPORT PHONE �S)GNATU i C/.1fS , 0 REPRESENTING OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME 0 ❑ LOCAL AGENCY ❑ OTHER 0 2 .✓ -cc. [ADDRESS D/S 9 ShawSTRE�°a SQ�racrry CINE 4S' P L4 NAME ,,AA CONTACT PERSON PHON/E03 _ Fn M Sh e ❑ UNKNOWN kvi GI A-e1 r ( /tD)�(a/-0 f; R a ADDRESS co cc 3olS �rac��sltaw �oac S��rar+lt�l ��- ��z7 STREET CTTV STATE 21P FACILITY NAME(IF APPLICABLE) OPERATOR PHONE 06 a ADDRESS y�o C a 1rcr IAJA 14S7'�� / San S� 47) P E, CROSS STREET TYPE OF AREA ®'COMMERCIAL ❑ INDUSTRIAL❑RURAL TYPE OF BUSINESS X] RETAIL FUEL STATION ` ❑RESIDENTIAL ❑OTHER ❑ FARM ❑ OTHER LOCALAGENCY AGENCY NAME CONTACTPERSON p PHONE w REGIONAL BOARd PHONE y (1) NAME QUANTITY LOST(GALLONS) o w ea 4d Cia PZ �'UNKNOWN J N ❑ UNKNOWN z 7 � DATE DISCOVERED G HOW DISCOVERED ❑ INVENTORY CONTROL E] SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS /M ✓M / D p v Y ❑ TANK TEST E:] TANK REMOVAL ❑ OTHER (� e O✓LLQ-- DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) W M M D D y y UNKNOWN ❑ REMOVE CONTENTS E] REPLACE TANK E] CLOSE TANK HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE p 5a YES ❑ NO IF YES,DATE /M M D D Y ❑ OTHER (/ w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) ❑ TANK LEAK ❑ UNKNOWNDj6O P GAL. FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE Q ❑ PIPING LEAK AGE YRS ❑ STEELElCORROSION ❑ UNKNOWN OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL OTHER 4D0$p- "j y� W w CHECK ONE ONLY UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY zN ¢< SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) cr U y ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) z ❑ CAP SITE(CD) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) w ❑ CONTAINMENT BARRIER(CB) EXCAVATE&TREAT(ET) r ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) ti z z w 8 HSC 05(4167)