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 5eYEs ❑ NO REPORTED THIS.INFORMATION TO LOCAL OFFICIALS PURSUANT TO SECTION 25180.7 OF R ! FCASIEx THE H S YCODE POR TEM Y MO / DI CJy � b f l SIGNE e� DATE } NAME OF YIDYAL aFILING REP RL PHONE �p^ 3 SIGNATURE a—, / '��•/ COMPANY OR AGENCY N E oW REPRESE TING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD 0 LOCAL AGENCY ❑ OTHER ��/n CF _ a ADDRESS !! 0. S7`�., STREET CRV STATE 21P w NAME M,, ,� J // pp CONTACTPERSON /P,HONE m� s�aC(«dY1 "V'�^�1-��CJ'C� El G �� J�o n �W c/ a o5" R a ADDRESS j)��' ///� ] 1r'f L (^ / ! �, / _) h Icr .L��S. STREEf J`-f�t.. `�-zJY W CRY STATE 21P FACILITY NAME(IF APPLICABLE) OPERATOR PHONE S S-DGar ah , Sl.{ S c ) 0 t_' ADDRESS 3� /STREE� CRV COUNTY ZIP CROSS STREET TYPE OF AREA ❑COMMERCIAL {^ INDUSTRIAL RURAL TYPE OF BUSINESS � RETAIL FUEL STATION �L,�_ RESIDENTIAL ❑OTHER ❑ FARM E-ETHER., L4 (I W) LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE w� w REGIONAL BO'AR/D� PHONE CL (�) NAME QUANTITY LOST(GALLONS) v o ❑ UNKNOWN Q J ~0 (2) (n Z ❑ UNKNOWN Z DATE DISCOVERED HOW DISCOVERED F7 INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS w M M o D " v v TANK TEST ❑ TANK REMOVAL ❑ OTHER Lu ~ DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) UNKNOWN F-] REMOVE CONTENTS ❑ REPLACE TANK ❑ CLOSE TANK W M M D D V Y l e/HAS DISCHARGE BEEN STOPPED? ❑ REPAIR TANK c, , (,❑( RAE-P^AIR PIPING ❑ CHANGE PROCEDURE -p ❑ YES ❑ NO IF YES,DATEM M o p y y I o I `QTHER w SOURCE OF DISCHARGE TANKS ONLY/CAPACITY MATERIAL CAUSE(S) ❑ TANK LEAK KNOWN GAL. ❑ FIBERGLASS ❑ OVERFILL ❑ RUPTURE FAILURE ❑ PIPING LEAK AGE YRS STEEL ❑ CORROSION t UNKNOWN ❑ OTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER Lu Lu CHECK ONE ONLY UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY zcl) 2 a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS O SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) U N ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED ❑ EVALUATING CLEANUP ALTERNATIVES CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) a z ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) Lu F-] CONTAINMENT BARRIER(CB) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) w ❑ TREATMENT AT HOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) 1 a,esu 7"c� :� �Ci �.u�-r te s oh a ui HSC OS(4B7)