Laserfiche WebLink
Y <br /> G 1 UNDERGROUND STORAGE AK UNAUTHORIZED RELEASE (LEAK)/E,4NTAMINATION SITE REPORT <br /> C� / HASSTATE OFFICE OF EMERGENCY SERVICES FOR.EOCALAGENCY USE ONLY <br /> BEEN I <br /> EMERGENCY �,^ REppgT FLED? t HEREBY CERTIFY THAT 1 AM A OESIiiNtwD GOVERNMENT EMPLOYEE ANDTHAT I HAVEN. <br /> YES LJ NO Q YES L� NO REPORTED THIS INFORMATION TO LOCAL 4FFICIA4PURSUANT TO SECTION 75180.1 OF- <br /> REPORT DATE CASE• THE HEALTH AIDSAFTY CODE { <br /> OM TDA O S /Y �,•��,_9P <br /> SMNED i�r DATE <br /> twAOORE�SS <br /> MEOFINDIVIDUAL FILING REPORT PHONE 'I SIGNATURE <br /> C / O� �, ( Zc91 Yom"34 L� <br /> PRESE OWNERIOPERATOR REGIONALBOARD COMPANY OR AGENCY NAME / _ 'L/ <br /> LOCALAGENCY OTHERS, " �7 /CC /k4 7h Se/7/tCf_.r <br /> Ys <br /> 'STREET CRY �I ' 4TATE ZIP <br /> NAME _ PHONE <br /> CONTACT PERSON 'I ' <br /> ❑ UNKNOWN �Q lW// 5991�i17. <br /> g ADDRESS q <br /> /065PGo. cl s R`E ve, <br /> �// Cm :T STATE av <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> r✓(C -r/ n1 Q q ( 7Co <br /> p ADDRESS' , <br /> O �CJf� S4cvi+GC oF�, /Y%PO/� <br /> ' srREEr cm ':I Dourrtr v <br /> 55 CROSS STREET TYPE OF AREA COMMERCIAL Q INDUSTRIAL Q RURAL TYPEOFBUSINESS gETAR FUEL STATION <br /> m O RESIDENTIAL [—]OTHER 'I O FARM [:] OTHER j <br /> b - LOCALAGENCV AGENCY NAME CONTACTPERSON PHONE <br /> �w STP3{ <br /> REGIONAL BOARD !j PHONE <br /> i lf) NAME - [ QUANTITY LOST(GALLONS) <br /> / UIue ne Cp UNKNOWN <br /> r <br /> 0�0 (2) <br /> w Ffry y/ �e,7 l Z P�� f NKNDWN <br /> DATE DISCOVEREDpYNOW DISCOVERED I RYCONTROL © SUBSURFACEMONRORNG Q NUISANCEODNDfOONS <br /> w I NK <br /> Y E] TATEST TANK REMOVAL Q OTHER <br /> DAM M D D / <br />:+ <br /> DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> i0. UNKNOWN REMOVE CONTENTS REPLACE TANK Q CLOSE TANK <br /> M M D 0 Y _ Y <br /> M HAS DISCHARGE BEEN STOPPED 7 L-j REPAIR TANK REPAIRPIPING CHANGE PROCEDURE <br /> S YES NOIF YES.DATE uI mi 01 DI r Y 0 OTHER <br /> uI SOURCE OF DISCHARGE TANKS ONLYrAPACITY MATERIAL _ CAUSE(S) <br /> N� E::] TANKLEAK UNKNOWN GAL Q FBERGVSS E] OVERFILL Q RUPTUREiFAILURE <br /> 0 PIPINGLEAK AGE YRS STEEL -...� CORROSION ❑ UNKNOWN <br /> O OTHER Q UNKNOWN ,� OTHER , SPILL O OTHER <br /> ww CNECKONEONLY t <br /> tU� [::] UNDETERMINED a SOILONLY GROUNDWATER FDRINKNGWATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECKONEONLY j{ <br /> iq ❑ <br /> ¢Z SITE INVESTIGATION IN PROGRESS(DEFINING EXTENT OF PROBLEM) Q CLEANUP IN PROGRESS[—] SIGNED OFF p.EANUP COMPLETEDOR UNNECESSARY) <br /> m � NO ACTION TAKEN Q POST CLEANUP MONITORING IN PROGRESS Q NO FUNDS AVAILABLE TO PROCEED Q EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) lid <br /> 54.. CAPSITE(CO) 0 EXCAVATE&DISPOSE(ED) REMOVE FREE PRODUCT(M ENHANCED BIODEGRADATION(M <br /> CONTAINMENT BARRIER(CBj EXCAVATE TREAT(ETI �` PUMP6TREAT GROUNDWATER(Gn REPLACE SUPPLY(RS) <br /> TREATMENT AT HOOKUP(HU) O^ NO ACTION REQUIRED INA) i OTHER(OT) <br /> .y- Cpn TQC m/✓ea�rcm /Atc/CCcr.�er!'` %`/ Sur/ .SGS/P j"e Sct3 0� �attf /e.kc�ve�P- <br /> w arsessi,..e„�/ wL // �P op CfSS� ?'w GlE Ton ivr i�0. ��' K4�uG Q <br /> Qr.C�ic� <br /> C,4' C, 4S I�CeL.ii-off �yoij /vca0 ��ccl ` cw-P�ccy, <br /> H9G�1�1 <br /> _. _ <br />