Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE(LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVIC FOR LOCAL AGENCY Uwv'E ONLY <br /> REPORT BEEN FUD? <br /> Q YES ND Q YES NO i HERESY CEATIFYTHA.1,HAVE t iS7Ai9U7EaTHIS INFORM Alli*ACtX51iDING T THE: <br /> 1?i IBUTI SH T INS UCTK)N S <br /> REPORT DATE ON THE BACK PAGE OFTHIS FO1RkU <br /> CASES <br /> / (fes j.,( <br /> M ` M 6_ T S T- Y SlfaM } <br /> 77. <br /> DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE TURF <br /> w REPRESEING QOWIERIDPERATOR Q REGIONAL BOARD COMPANY OR AGENCY NAME <br /> o LOCALAGENCY Q OTHER <br /> a A KESS' <br /> 040 ` <br /> T.T. <br /> N EG NTACT PERSON,r PHONE <br /> � ) UNKNOWN Eecrs�-H (7-13) <br /> ILa ADD •! <br /> itzkx -STfiEFT CITY <br /> FACILITY NAME(f APPLICABLE) r c,1211w OPERATOR PHONE. <br /> ADDRESS <br /> W "*. STREET 457- <br /> CITY z 4 .CCUNtY6 <br /> CROSS STREET <br /> tg LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE l <br /> li LU <br /> UJ A�*Jk" <br /> LU REGIONAL BOARD/ <br /> (PHONE <br /> f {� <br /> 4 <br /> cn V) NAME QUANTITY LOST(GALLONS) <br /> q �: V :(jt7 N Cs t E::] UNKNOWN <br /> mz' <br /> UNKNOWN <br /> i <br /> DATE DISCOVERED / HOW DISCOVERED Q INVENTORY CONTROL SUBSURFACE MONITORING NUISANCE CONDITIONS. <br /> Lij <br /> Q TANkTEST 0 ANK REMOVAL E OTHER <br /> T - <br /> m NATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> b. UNC <br /> W, CLO <br /> REMOVE CONTENTS SE TANK&REMOVE. Q REPAIRPIPING. <br /> HAS <br /> US ARGE BEEN STOPPED 7 +� Q REPAIR TANK Q CLOSE TANK&FILL IN PLACE.'Q CHANGE PROCEDURE. <br /> a S Q NOIF YES:DATE •: C7 Yy ❑REPLACE TANK' Q OTHER <br /> M ol :v <br /> SOURCE OF DISCHARGE CAUSE(S} <br /> w <br /> TANK LEAK: UNKNOWN OVERFILL ❑ RUPTUREIFAILURE Q SPILL <br /> PIPING LEAK Q: OTHER ED CORROSION KNOWN :L OTHER <br /> w w CHECK O ONLY <br /> CLt <br /> UNDETERMINED Q SOIL ONLYGtIiGUNDWATER. Q' DRINKINCaWATETi (CHECK:ONLY.IFINATER WELLS MAVE:ACTUALLYBEEN4FFECTED), <br /> CHECK ONE ONLY <br /> NO.ACTION TAKEN n RELIMINARYSITL`-ASSESSMENT WORKPLAN.SUBMITTED Q POLLUTION CHARACTERIZATION. <br /> w <br /> Boll LEAK 8I ING CONFI M90 PRELIMINARY91TE ASSESSMENT UNDCRWAY PO$T CLEA(VUP MUI�IttOR1 IN PROGRESS <br /> Q REMEDIATION PLAN F-1CASE CLOSED(oCL6ANUF'COMPLETED OR UNNECE88ARY} � CLEANUP UNDE#INiJ1V <br /> CHECK APPROPRIATE A ACTIONS) Q EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(FP) Q :ENHANCED:BIO DEGRADATION(ITy <br /> wavArA�Op oEir <br /> Q CAP SITE(CD), F] EXCAVATE a TREAT(ETj PUMP S TREAT GROUNOVY}ITEFt{GT}Q REPT T4CE SUPPLY:.(RS) <br /> � .: .CONTACNMENT4)ARRIER:(CB} Q NOACTIONREQUIRED(NA) Q 'TREATMENT ATHOOKUP,0. j. Q VENT:SOlL(VS) <br /> VACUUM HXTRACT(VE) zo <br /> OTHEOI.(t7i).,., <br /> r <br /> 00 <br /> V Hsc 05 la" <br />