UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY REPORT BEEN FILED? I HEREBY CERTIFY THAT 1 AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I HAVE YES No E::] YES NO REPQRTETHIS INFORMATION TO LOCAL OFFICIALS PURSUANT 70 SECTION 25180.E OF REPORT DATE �j T-,) yii CASE s THE TH AND SAFTY DE. Zzoj'M �M "' Dv SIG ED /ATE _ NAME OF INDIVIDUAL FILING REPORT PHONE C-;-- ;C5 SIGNATURE l w REPRESENTING OWNENOPERATOR ❑ REGIONALBOARD COMPANY OR AGENCY NAME cr ❑ LOCAL AGENCY [:] OTHERCL S Ill DDRESS 9�ao STREET CITY STATE ZIP w NAME CONTACT PERSON x r PHONE Zcr El UNKNOWN 2a ADDRESS 14Z Y A--� cc ,�. O r SOX 40Z C�•clC � c t�4 2 l STREET CRY STATE Zip FACILITY NAME(IF APPLICABLE) OPERATOR PHONE 0 ADDRESS SToc-c 0 W STREET CRY COUNTY ZIP v7 CROSSSTRREEET� A may,/ TYPE OF AREA COMMERCIAL❑INDUSTRIAL RURAL TYPEOFIBUSINESS RETAIL FUEL STATION �F-d � k—= / O RESIDENTIAL F--]OTHER ❑ FARM ❑ OTHER LOCAL AGE�Y AGENCY NAME CONTACT PERSON PHONE Pw w wLLJREGIONAL BOARD PHONE as ul (1) NAME QUANTITY LOST(GALLONS) UNKNOWN cn ❑ UNKNOWN z DATE DISCOVERED HOW DISCOVERED INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS uj L/M v M `D D 'Y U v ❑ TANK TEST F-] TANKREMOVAL ❑ OTHER DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) 2 M M D .1 YJ YJ UNKNOWN d REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK w HAS DISC ESRGE❑BEENO TIOF YES DATE � 2D`=D Cw® v ❑ OTHERREPAIRTANK ❑ REPAIR PIPING E] CHANGE PROCEDURE w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) TANK LEAK ❑ UNKNOWN /` C GAL. FIBERGLASS ❑ OVERFILL ❑ RUPTURE/FAILURE CIE ❑ PIPING LEAK AGE _YRS STEEL ❑ CORROSION Irl UNKNOWN OTHER SLI ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER w w CHECK ONE ONLY a- [::] ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) F CHECK ONE ONLY zN 2< lef SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) Er.;5 U ❑ 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 BIODEGRADATION(IT) 00 ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) cc ❑ TREATMENT AT HOOKUP(HU) ElNO ACTION REQUIRED(NA) ❑ OTHER(OT) f1W& t1 ij- 1_1 4T 4er r}-t� Ti4-,c/�-5 ,DSII, Lr•�l�S i� �E �p1�9-�-rE-1� r.��T,� ,l,�pcl�� ui�c.t__ z �Y ��14 — f� ��-Gam(/T-y�Tr�c! r � 1�cry S ;�r�T I✓ ,�r� HSC 05(4487)