Laserfiche WebLink
t I " <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FQfiLOCALAGENCY,USE ONLY <br /> REPORT BEEN FILER 7 <br /> ❑ YES NO YES ❑ NO ?HEREBY CERTIF,YTHA71 HAVE DISTRIBUTED THIS INFORMATION,ACCORDING TO THE, <br />( <br /> REPORT DATE DISTRIBUTION SHOWN ON THE INSTRUCTION SHEET ON THE BACK PkGE OF THIS FORl4C. <br /> II �// CASE a <br /> q <br />[ OMI �MI � � y k <br /> I SIGNED. DATE <br /> NAME OF INDIWOUAL FILING REPORT (fPHONE SIGNATURE <br /> m <br /> REP S NTING ❑ OWNERIOP &TOR ❑ REGIONAL BOARD COMPANY OR AGENCY AME <br /> LOCAL AGENCY ❑ OTHER ,� ^'�` �� /,7 t <br /> ow[ —TD D I�f�� ca'J 3 i-, J lo Cj Y� S-fo c./i�r[�-�- FCC A <br /> I TLr STREET cm E! STATE <br /> w NAME / ,n CpNTACTPERSON rPH'O}NE 1 ZIP <br /> Z� I G out L� (�� {J LLQ Ie-1 ❑ UNKNOWN � r 4nS <br /> v <br /> O <br /> AooaEss ILn I _ <br /> tj <br /> 21 3 C11- <br /> STREET STATE <br /> ZIP <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> z 180g::f� V,2-3 j-3 i <br /> ADDRESSf 1 a- /�' it _ } <br /> w 5T EEf �~ 1 CITY COUNTY ZIP <br /> CROSS STREET <br /> z LOCAL AGENCY AGENCY NAME CONTACTPERSON II PHONE <br /> In <br /> Lu <br /> SCI-41 W, <br /> �w REGIONAL BOARD} ? PHONE <br /> (t) NAME QUANTITY LOST(GALLONS) <br /> LU <br /> UNKNOWN <br /> m> (2) <br /> Z)z x I <br /> UNKNOWN <br /> DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Lu <br /> z �Jj ii �/ }�(/ <br /> :I- f M{ &MI i of O l yl s/ y ❑ TANK TEST ❑ TANK REMOVAL OTHER <br /> r <br /> m DATE OfSCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> a ![ <br /> } UNKNOWN ❑REMOVE CONTENTS9CLOSETANK&REMOVE REPAIR PIPING <br /> ESE, M o o Y Y I( <br /> HAS DISCHARGE BEEN STOPPED T (�} Q/ ❑REPAIR TANK CLOSE TANK&FILL IN PLACE E:]CHANGE PROCEDURE <br /> Ln <br /> YES ❑ NO IF YES,DATE �MI J I ly y ❑REPlACE7ANK i ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> Z) Ll TANK LEAK UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAELURE E:] SPILL <br /> cn O U PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN Q OTHER <br /> w w CHECK ONE ONLY f <br /> o ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER;.(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> zy NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTER POLLUTION CHARACTERIZATION <br /> w p x <br /> r ❑ LEAK SETNG CONFIRMED ❑ PRELIMINARYSIT£ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> L)N ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED 910 DEGRADATION(IT) <br /> J IME BCR FOR XTwl I L <br /> o O r_] CAP SITE (CD) ❑ EXCAVATE&TREAT(ET) E:] PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> Luo ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA} ❑ TREATMENT AT HOOKUP(HU} ❑ VENT SOIL(VS) <br /> cr <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) If <br /> I <br /> �' ..St�[� j'Z.,E-C, �� c2/.L�'LG � G�!�.���c.��' -��i_.+•. <br /> HSC 0$[8'90} <br /> I <br /> I <br />