UAR/PROP 65_PRE 2019 - Laserfiche WebLink

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O �o UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY F-1 YES NO ❑ YES �NO REPORT BEEN FILED v 1 HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE DISTRIBUTION SHOWN ON THE4NSTRLICTION SHEq ON THE BACK PAGE OF THIS FORM. REPORT DATE CASE t faf y 44 0 i L/M M y SIGNED DATE NAME OF INDIVIDUAL FILING REPORT PHONE AT SIGNURE mac- - Ze- 'A,8_ `� y� AJAJ&414 REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONALBOARD [COMPANY OR AGENCY NAME r- p IOCAL AGENCY ❑ OTHER � ' Av'Ir 0A ffi&41 44, Ir ADDRESS Yqyj 2 a'z - 09 STREET V , v tT STATE ZAP Lu NAMELOA CONTACT PERSON PHONE z UNKNOWN ) se4 ❑ CL a A'J\D�JDR�/E�y S 0. �/7/may 9 &V, STREET cm STATE ZIP FACILITY NAME(IF APPLICABLE) OPERATOR PHONE LL ( Zoq) 9s -sag U ADDRESS 4allv.?aayw Iti 9f Z W STREET ��Ia CITY COUNTY ZIP ~ CROSS S REET N kkr O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE z� Lu �k 341E ww REGIONAL BOARD PHONE (1) NAME QUANTITY LOST(GALLONS)LU r U o ,1 v`1 J UNKNOWN m> (2) U)z eS UNKNOWN r DATE DISCOVERED s�y Y HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUIS CE CONDITIONS Z o MI IMI D� D v ` y ❑ TANK TEST ❑ TANK REMOVAL OTHER"J wk_ a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) m a Q UNKNOWN ❑REMOVE CONTENTS a CLOSE TANK 8 REMOVE EPAIR PIPING w M M D D Y Y HAS DISCHARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE CHANGE PROCEDURE U n U) YES ❑ NO IF YES.DATE C)M 1AI/ I D C V Y G El REPLACE TANK ❑ OTHER 111��" D SOURCE OF DISCHARGE CAUSE(S) w ¢� ❑ TANK LEAK ❑ UNKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL �a U)v ' PIPING LEAK ❑ OTHER ❑ CORROSION ❑ UNKNOWN ❑ OTHER L.w CHECK ONE ONLY rn a v UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) CHECK ONE ONLY z ❑ NO ACTION TAKEN F__] PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTER17ATION Q w, LEAK BEING CONFIRMED O PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS U F-] REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE E DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIODEGRADATION(IT) J (SEE BACK TOR DETAlS) Z ❑ a CAP SITE(CD) ❑ O EXCAVATE 8 TREAT(ET) ❑ PUMP E TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) w w a ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) �, �c,;,�`l,f;✓� ll.`t�' ��:� .+ t Pel I KlSe�1l�jGc 7� _ f iii t �F F 2 co ui tangy I r rL 0 0 U HSC 05(WO)