Laserfiche WebLink
UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> ❑ YES ZNO REPORT BEEN FILED 7 ❑ YES Zr NO I HEREBY CERTIFY THAT I HAVE DISTRIBUTED THIS IN TION ACCORDING TO THE <br /> REPORT DATE <br /> DISTRIBUTION SHOWN ON THE INSTRU HE E BACK PAGE OF THIS FORM, <br /> SIGNED <br /> CASE <br /> } L <br /> NAME OF INDIVIDUAL FILING ORT PHONE SIGNATURE DATE <br /> ec,✓1 q/ G� 1 i 1���a.3`I <br /> w REPRESENTING EDO <br /> r Wt+lER/OIO <br /> PERATOR Q REGNAL BOARD COMPANY OR AGENCY NAME <br /> LDCALAGENCY Q OTHER <br /> IE ADDRESS h <br /> ' S ET JC.* cm G TATE Z � <br /> NAME CONTACT PERSON PHONE <br /> J 1 <br /> z a �S r)�+n �QL�r do- UNKNOWN / o <br /> N a ADDRESS <br /> w <br /> cc STREET �- y53zv <br /> lip"I c�Tv �% STATE ,r <br /> FACILITY NAME(IF APPLICABLE) OPERATOR �/J� /PHONE py <br /> 1 4 ADDRESS C /, O VlQC 1�L1 n?rC-76 Z1 <br /> OSTREET <br /> y <br /> CROS 5 ST EET c� SSG COUNTY3 / IP <br /> S <br /> z LOCALAGENCY AGENCY NAME CONTACT PERSON PHONE <br /> ssc pis <br /> w U Nt ti e 4 ; �-I.ti ( zcrl 1 yb�-3yyy <br /> w w REGIONAL BOARD <br /> PHONE <br /> a Cv ��QL� <br /> 4 NAME QUANTITY LOST(GALLONS) <br /> <D Cf S c� `� I NKNOWN <br /> cn> (2) <br /> U)2 <br /> UNKNOWN <br /> z DATE DISCOVERED HOW DISCOVERED SUBSURFACE MONITORING NUISANCE CONDITIONS <br /> Q O INVENTORY CONTROLEJ <br /> O v it o [Y r TANK TEST TANK REMOVAL a OTHER <br /> 1 4 DATE DISCHARGE BEGAN ���, METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Q u D Y y ErUNKNOWN E]REMOVE CONTENTS CLOSE TANK a REMOVE REPAIR PIPING <br /> p HAS DISCHARGE BEEN S PPED? Q REPAIR TANK CLOSE TANK&FILL IN PLACE CHANGE PROCEDURE <br /> `n ❑ YES NO sF YES DATE rr J p r Y E]REPLACE TANK Q'6THER kVj- <i- Uq I y-R <br /> o <br /> SOURCE OF DISCHARGE <br /> CAUSE(S) <br /> tor TANK LEAKNKNOWN OVERFILL a RUPTUREIFAILURE SPILL <br /> cn V PIPING LEAK OTHER CORROSIONNKNOWN OTHER <br /> Lu w CHECK ONE LY <br /> rn a <br /> L) UNDETERMINED SOIL ONLY 0 GROUNDWATER ❑ DRINKING WATER (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) 1 <br /> CHECK OY (L,' <br /> z 1 CTK)N TAKEN a PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED O POLLUTION CHARACTERIZATION <br /> cr Lo LEAK BEING CONFIRMED PRELIMINARY SITE ASSESSMENT UNDERWAY 0 POST CLEANUP MONITORING IN PROGRESS <br /> ' o O REMEDIATION PLAN a CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) <br /> tsEE arx ran OEfA{81 Q EXCAVATE 6 DISPOSE(ED) 0 REMOVE FREE PRODUCT(FP) ENHANCED Si0 DEGRADATION(IT) <br /> a z CAP SITE(CD) 0 EXCAVATE&TREAT(ET) O PUMP s TREAT GROUNDWATER(GT)0 REPLACE SUPPLY(RS) <br /> w0 <br /> w O CONTAINMENT BARRIER(CB} E] NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS) <br /> a: <br /> O VACUUMEXTRACT(VE) 0 OTHER(OT) <br /> Iz � /! `7 e/LV <br /> c� <br /> ' me 051&" <br />