Laserfiche WebLink
a <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? <br /> ❑ YES NO ❑ YES ❑ No HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> DISTRIBUTIONSHOWN.ONTHEINSTRUCTION HEET:ONTHEBACKPAGEOFTHIS FOR. <br /> REPORT DATE �/ CASE i t <br /> OM / MI '5 (/jam/ �/Y $IIa \ <br /> DA E <br /> NAME OF INDIVIDUAL FILING REPORT PHONE S NATURE <br /> c` O stn I,p ( H�0�5-033 <br /> REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAMEQ <br /> p &LOCAL AGENCY ❑ OTHER <br /> cc ADDRESS <br /> vv,yW( ;^l 3 aA <br /> CITY <br /> STATE <br /> wNAME CONTACT PERSON PHONE 9 <br /> z �✓ N..V I�--�J V t x ❑ UNKNOWN rb 5'�� 1 C V ,Q�]\�-IQ <br /> oQ <br /> ' ADDRESS <br /> '1 G✓VI.YOA ZIP <br /> FACILITY NAME(IF APPLICABLE) PERATOR PHONE <br /> M <br /> ADDRESS CIA <br /> �QY' <br /> w V! lsT Er \ clTr Q LV (,l(Ih zla <br /> courm <br /> F CROSS STREET <br /> L <br /> 0 LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> W ��o �� ,�vv l4oSV��ok�, ( l) <br /> w w REGIONAL BOARD PHONE <br /> J <br /> a¢ ( ) <br /> W <br /> (1} F NAME QUANTITY LOST(GALLONS) <br /> z> UNKNOWN <br /> Q J <br /> m (2) <br /> N Z / <br /> ❑ UNKNOWN <br /> z DATE DISCOVERED Q //�, HOW DISCOVERED ❑ INVENTORY CONTROL ❑ SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> w OMI MIIDI (v� Fir ❑ TANK TEST TANK REMOVAL ❑ OTHER <br /> w <br /> a DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> m <br /> a <br /> UNKNOWN ❑REMOVE CONTENTS CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> cc Lu M M D D Y Y <br /> p HAS DISCHARGE BEEN STOPPED? Q E]REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> o YES ❑ NO IF YES,DATE l MI D f r ❑REPLACE TANK ❑ OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ww <br /> Da ❑ TANK LEAK NKNOWN ❑ OVERFILL ❑ RUPTURE/FAILURE E:] SPILL <br /> c v ❑ PIPING LEAK OTHER ❑ CORROSION UNKNOWN E:]"OTHER <br /> Lu w CHECK ONE ONLY <br /> U _..UNDETERMINED ❑ SOIL ONLY ❑.__GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY,IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECk ONE ONLY <br /> z F-] NOACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> a- <br /> D F-] LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY E:] POST CLEANUP MONITORING IN PROGRESS <br /> U ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUP UNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(IT) <br /> J (SEE SACK FOR DOAI S) <br /> a o ❑ CAP SITE(CD) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w< ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> Q ❑ VACUUM EXTRACT(VE) ❑ OTHER(OT) <br /> U <br /> z <br /> 0 c U <br /> HSC 0.5(890) <br />