Laserfiche WebLink
00 • t,tp9 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)I CONTAMI ATION SITE REPOR <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY App 8 <br /> REPORT BEEN FILED T 1 HEREBY CERi1FYTHATI HA STRIBUTED'HI$ F,=MA aK <br /> Ac.ICQRDI�{ THS <br /> ❑ YES NO ❑ YES NO DI ( TION N-ON ✓WSTRUCTg4 SHcL�Yff''0 p) C AG { M <br /> REPORTDATE'j //.�� CASES /+`/ (�� <br /> QuI Z O y r SIGNED TAD T6 <br /> NAMEOFINDIVID FILING REPORT PHONE SIG TU E (� <br /> 11 -2 NoIf�•1` 6z <br /> GAL BOACMANY OR AGENCY NAME <br /> REPRESENTING ` rQWNEROPERATOR ❑ <br /> S ❑ LOCAL AGENCY ❑ OTHER ` O S co <br /> ¢ <br /> ADDRESS ` \��`' LL y� /� �y _LC <br /> �sej i LL C <br /> `�U0 UEAD 1 kLL-- (LOP00 , SQ E , L�-J STATE IIP <br /> 8 REE cm <br /> CONTACTPERSON PHONE <br /> w NAME _ Q ( <br /> ZQ <br /> UNKNOWN �.7 \\AL-S TZ):J ( 11(0) 1� ''/Z/I ICJ <br /> n<y ADDRESS /� cp, 9 SL�O` <br /> s 1�J2TCa <_C��17 1-E 1 LL RU Ac7) S V T �, I ZCT cmZOS�I ( LLC STATE P . <br /> STREET <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o �O tll oSCo UNxtrL 6nl I A l ) <br /> a <br /> ADDRESS <br /> ` S-CbL\TO L' <br /> s y lb`l �Rc \��E�E Cm couNtt 1p <br /> yCROSS STREET <br /> N\ �2�4� LAIvC <br /> O LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> w� SPAr.) �OA v °9) q(A 31+ <br /> Z. REGIONAL BOARD ` 1 PHONE <br /> < CtlU-1LPcL— �/ACL-I - Si�� ti(L(LiYJ [p.( � `L l ( ) <br /> w (1) <br /> NAME QUANTITY LOST(GALLONS) <br /> o \ A n T$�Nj UNKNOWN <br /> w l <br /> O <br /> j? ❑ UNKNOWN <br /> N <br /> DATE DISCOVERED // II^�� HOW DISCOVERED 1❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> �o XP oI V r r ❑ TANK TEST ,12 ,ANK REMOVAL ❑ OTHER <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) O <br /> a <br /> a u o r rUNKNOWN ❑REMOVE CONTENTS OSE TANK&REMOVE <br /> REPAIR PIPING <br /> HAS DISCHARGE BEEN STOPPED? I ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o " YES ❑ NO IF YES,DATE u uI w U Y O r ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSES) <br /> ¢� ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTUREIFAILURE ❑ SPILL <br /> GLEAK ❑ OTHER ❑ CORROSION - UNKNOWN ❑ OTHER <br /> ww CHECKONEONLY <br /> 'Q ❑ UNDETERMINED ❑ SOILONLV X GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> Z w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> w Z ❑ <br /> j� ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS <br /> O w ❑ ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) �LCLEANUP UNDERWAY <br /> REMEDIATION PLAN i^- - <br /> CHECKAPPROPRIATEACTION(S) `0_"CAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) <br /> SITE <br /> (CO) <br /> f�� _ <br /> i ❑ CAP SITE ) ❑ EXCAVATE 8 TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) <br /> wo ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> < ❑ VACUUM EXTRACT(VE) J;4-OTHER(OT) ON 60 TSD(� (14-MINCED L AT 013 <br /> y < wf ti Br a�.J" r✓fl� G' <br /> 8 <br /> XSC 61ASW <br />