UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) I CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY REPORT BEEN FILED? I HEREBY CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT l HAVE ❑ YES NO Q YES ❑ NO REPORTED THIS INFORMATION TO LOC OFFICIALS PURSUANT TO SECTfON 25180.7 OF REPORT DATE CASE x THE HAL�H AND AFTY COD ^�d M M v o F v o Y SIGNED DATE, NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE >- Acirles `n COMPANY OR AGENCY NAME w REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD L N D Cc ~ Sj /7 0 © LOCAL AGENCY ❑ OTHER O CL Ld cc ADDRESS �, 1 r0-0� �/ V 0 r• 1,a Ze 146w STREET ' C � CITY /y STATE 5/z D ZIP NAME CONTACT PERSON PHONE ( U Z� �� ❑ UNKNOWN 1(;r ( ( � ) qa�'D"/�Q S� IL ADDRESS 2 6 STREET CITY L' ti a STATE L4 ZIP FACILITY NAME(IF APPLICABLE) OPERATOR PHONE ADDRESS W 7 )0O MVIybi- CJ STREET Si��-�� CITY JAN (/)Q ul COUNTY 756;Z ('2--ZIP I CROSS STREET TYPE OF AREA ❑ ❑ TYPE OF BUSINESS COMMERCIAL INDUSTRIAL RURAL RETAIL FUEL STATION Hommfr L.Z tom RESIDENTIAL EZOTHER iX-,,pcP(c�r+mr,T�•(I ❑ FARM ❑ OTHER LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE c v� � ~w Za 60�"eti�;.�.�. LC7 2, wREGIONAL BOARD / PHONE (1) NAME QUANTITY LOST(GALLONS) UNKNOWN za> J ~0 (2) > UNKNOWN i DATE DISCOVERED HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING NUISANCE CONDITIONS Lu i M ' M 2-.l o '3yl F Y ❑ TANK TEST JZ TANK REMOVAL ❑ OTHER DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) UNKNOWN REMOVE CONTENTS ❑ REPLACE TANK iz CLOSE TANK Cc w M M D D V Y pHAS DISCHARGE BEEN STOPPED? F REPAIR TANK E�l El REPAIR PIPING CHANGE PROCEDURE pYES ❑ NO IF YES,DATE f M 7.M _�l o DI �—Y v ❑ OTHER w SOURCE OF DISCHARGE TANKS ONLY^/CAPACITY MATERIAL CAUSE(S) F7 TANK LEAK Z UNKNOWN , )- 3 Ii iC� GAL. ❑ FIBERGLASS a OVERFILL [�j RUPTURE/FAILURE PIPING LEAK AGE YRS ® STEEL ❑ CORROSION ® UNKNOWN ❑ OTHER UNKNOWN ❑ OTHER SPILL ❑ OTHER Lu w CHECK ONE ONLY UNDETERMINED SOILONLY GROUNDWATER DRINKING WATER• (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY z� a a SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) ❑ CLEANUP IN PROGRESS ❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY) U rn ❑ NO ACTION TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAILABLE TO PROCEED 0 EVALUATING CLEANUP ALTERNATIVES CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) z ❑ CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ENHANCED BIO DEGRADATION(IT) 00 wCONTAINMENT BARRIER(CB) EXCAVATE&TREAT(ET) PUMP&TREAT GROUNDWATER(GT) REPLACE SUPPLY(RS) 2 ❑ TREATMENT AT HOOKUP(HU) O NO ACTION REQUIRED(NA) OTHER(OT) jE�N (10A. /t^l91'lievc+t-�taA) dUr, -fry,, r'P`YltyJ zL j 1�u r 7"�1 P/' S l Gr5S Pss4n •% w 6—// be re erir><ca �o o%{llvr�/.vC c�,r��,� ' cdn�TGtt►%rnla 0� CCs /'�'C�utl'�� C g by o f yria A Sel(�xjj r/ 47 eNe HSC 05(4/87)