Laserfiche WebLink
UNDERG UND STORAGE TANK UNAUTHO ED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERV ES F L AGENCY USE ONLY <br /> REPORT BEEN FILED 7 <br /> YES .0 ❑ YES No E C RTIFYTHAT 1.:. D IBU HI FORMATION ACCORDING TO THE <br /> I T HOWN ON T UC ON THE SACK PA E F IS FORM <br /> R ORT DATE CASE t <br /> SIG <br /> MI MI v .:: ::. :. DATE . <br /> m NAAyJr; IN AL FILI PORT PH ) IGNA E �� <br /> w REPRES TING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD CQPN R GENCY NAM <br /> p LOCAL AGENCY ❑ OTHER __/✓��/'��p /� <br /> 2 ADOR <br /> //�`v//�( . (//('^ � /p. t ( C L STATE � IP <br /> Lu NAME.., nI CON'qACT PERSON PHONE <br /> z / / UNKNOWN <br /> 0 <br /> CL Q ADDRESS I�� 0� <br /> 9)a �� V v 'EEC/�?�nr <br /> w <br /> Q <br /> STREET ZIP <br /> FACILITY NAME(IF APPLICABLE) OPE TOR PHONE <br /> c ADDRESS <br /> J EET `/'CITr - - ` COUNTY <br /> w ZIP <br /> CROSS TR ET <br /> N l <br /> zz w LOCA GEI{CY_f /,� •• AGENCY NAME CONTACT PERSON PHONE <br /> fr/'//5 <br /> w U ( ) <br /> w w REGIONAL BOARD PHONE <br /> 9) (�) - NAME QUANTITY LOST(GALLONS) <br /> Q w � NKNOWN <br /> Q J <br /> m O (Z) <br /> Z <br /> y- ❑ UNKNOWN <br /> Z DATE DISCOVERED <br /> �j� /�/� HOW DISCOVERED ❑ VENTORY CONTROL ❑ SSURFACE MONITORING ❑ NUISANCE CONDI IONS <br /> w M� W DI ` r Y ❑ TANK TES TANK REMOVAL OTHER (.Q�1,. n <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHAR(CHECK ALL THAT APPLY) <br /> a <br /> Lu o o r r <br /> UNKNOWN E:]REMOVE CONTENTS CLOSE TANK b REMOVE REPAIR PIPING <br /> >o HAS DI HARGE BEEN STOPPED 7 ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> Lo YES ❑ NO IF YES.DATE I u d rl ❑REPLACE TANK a OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> w <br /> Q j ❑ TANK LEAK UNKNOWN ❑ OVERFILL ❑ PTURE/FAILURE ❑ SPILL <br /> u0i O O PIPING LEAK a OTHER O CORROSION UNKNOWN O OTHER <br /> w w CHECK <br /> 9)a NE ONLY <br /> cQi Z UNDETERMINED ❑ SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> i 9) ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> crw <br /> cc <br /> ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY E::] POST CLEANUP MONITORING IN PROGRESS <br /> y <br /> O a REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) a CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) a EXCAVATE E DISPOSE(ED) Q REMOVE FREE PRODUCT(FP) a ENHANCED BIODEGRADATION(IT) <br /> tsEE eAcK FOR DETA&M <br /> Q z ❑ CAP SITE(CD) ❑ EXCAVATE 3 TREAT(ET) ❑ PUMP a TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) F7 VENT SOIL(VS) <br /> ¢ <br /> 0o <br /> Lu <br /> w ❑ <br /> CONTAINMENT BARRIER(CB) <br /> ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> ui <br /> zm <br /> U <br /> NSC as ream <br />