Laserfiche WebLink
! _ N 7 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES :'FOR. LOCAL"AGENCY ..USE ONLY: <br /> REPORT BEEN FILED ?VES NO YES 1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ ❑ NO <br /> DISTRIBUTION SHOWN CW:THE WSiR TION.SHEET:O BACK PAGE OFTHIS FORM <br /> REPORT TE CASE •- <br /> ml yI 14 t'I' SIGNED DATE '.. <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> (42a KI <br /> w REPRESENTING ❑ pWNER/OPERATOR REGIONALBOARD COMPANY OR AGENCY NAME <br /> o LOCAL AGENCY ❑ OTHER U ;a 4n , (ul/hl(c l J.{`pA` 7 14 I-I eV ,y) <br /> ADDRESS L <br /> � 0 0 od a R S � STATE q � 2ol <br /> NAME ONWON PHONE <br /> n fka k, tj & E::] UNKNOWN 06 2MG/ j� �j <br /> J <br /> a a ADDRESS <br /> g I �7 S =TREE F9eSNo e, CITYS acK a y► ST IP <br /> ATEC4 <br /> FACILITY NAME (IF APPLICABLE) OPERATOR PHONE <br /> �`/ uck , w c ) <br /> Q ADDRESS �] F ,' ] <br /> I $ \ .AEEI' 2 �s N `� ,P/ CITY S O UHn <br /> nP <br /> CROSS STREET 1111 �� <br /> W <br /> O LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> Pw <br /> w Uj REGIONAL BOARD PHONE <br /> G �' w G FIl6i S60 <br /> N (1) NAME QUANTITY LOST (GALLONS) <br /> 2 V CJ �FiGt O rJS ❑ <br /> UNKNOWN <br /> mm O (2) <br /> Z <br /> ❑ UNKNOWN <br /> i- <br /> DATE OILSC�'OVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS 1 <br /> Nal I ul D1 of (�/Jj r, y ❑ TANK TEST TANK R MOVAI ❑ OTHER <br /> < DATE DISCHARGE BEGAN IAETiHD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) OQ <br /> UNKNOWN ❑ REMOVE CONTENTS ❑ CLOSE TANK & REMOVE ❑ REPAIR PIPING <br /> 0 HAS <br /> MDISCHARGE BEEN STOPPED T ❑ REPAIR TANK l ml 01 01 yl CLOSE TANK 8 FILLp/. <br /> IN PLACE ❑ CHANGE PROCEDURE <br /> ❑ YES ❑ NO IF VES, DATE MI j o DI r ❑ REPLACE TANK OTHER79M JcS / /u�o � <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> jw j ❑ TANK LEAK <UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> w ❑ PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER <br /> w CHECK ONE ONLY <br /> O UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> a ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> N ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> ❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIODEGRADATION (IT) <br /> Is[f ercx wn oEiusl <br /> < Z ❑ CAP SITE (CD) ❑ EXCAVATE & TREAT (ET) ❑ PUMP & TREAT GROUNDWATER (GT) ❑ REPLACE SUPPLY (RS) <br /> w a ❑ CONTAINMENT BARRIER (CS) ❑ NO ACTION REQUIRED INA) ❑ TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br /> ❑ VACUUM EXTRACT (VE) ❑ OTHER (OT) <br /> aiL �pf✓ irf<n/A ) 7c�.J �rv.�, Z — U ST Fr �it� avew O <br /> fe- assesses � r� � LC. � r u � <br /> is -92 , Fuad s% ek4t <br /> y�v 74b <br /> CoN � ��A �io.✓ r uiR� 6 _Ae GzPP�o ,� �e `` �' <br />